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Canakis A, Kesar V, Twery B, Ali O, Canakis J, Hudspath C, Goldberg EM. The Efficacy and Safety of Treatment Outcomes for Refractory Benign Esophageal Strictures Using a Novel Combination of Needle-Knife Stricturoplasty, Balloon Dilation, and Steroid Injection (with Video). GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:48-53. [PMID: 38476305 PMCID: PMC10928867 DOI: 10.1159/000527770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/03/2022] [Indexed: 03/14/2024]
Abstract
Background and Aims Benign esophageal strictures often present with dysphagia and can significantly impair a patient's quality of life, especially when refractory to standard endoscopic techniques. When repeat dilations fail to achieve an adequate luminal diameter or resolve dysphagia, further therapy with needle-knife or steroid injections is needed. However, patients can still clinically fail. To manage such strictures, we employed a novel combination of all three techniques. Methods Single-center case series of adult patients with benign strictures that were refractory to conventional endoscopic therapy and removable self-expanding metal stenting. Primary clinical success was defined as complete resolution in dysphagia. Secondary outcomes included periodic dilation index (frequency of dilations over the follow-up time), esophageal diameter changes, technical success, and complications. Results Four patients (median age 49.7 years old, interquartile range [IQR] 30-59) underwent endoscopic therapy for complex, benign strictures using our triple therapy technique. Etiologies of the strictures included peptic strictures (n = 3) and an anastomotic stricture (n = 1). There was 100% technical success rate with no associated adverse events. There was a 50% clinical success rate, with 1 additional patient having partial improvement in dysphagia. The median diameter of the esophagus before and after triple therapy was 3.2 mm (IQR 3.5-5.5) and 12.8 mm (IQR 11.7-14.2), respectively. The periodic dilation index was 6.3 before and 1.5 after triple therapy. The median length of follow-up was 362.5 days. Conclusion Triple combination therapy may be useful in benign strictures that are refractory to standard techniques. Larger studies are needed to validate these findings.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Varun Kesar
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Benjamin Twery
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Osman Ali
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Justin Canakis
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Caleb Hudspath
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Massachusetts, USA
| | - Eric M. Goldberg
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ren K, Wang J, Li Y, Li Z, Zhou Z, Wu K, Li Y, Ge X, Ren J, Han X. Paclitaxel-coated balloon catheter for benign esophageal stenosis in a rabbit model. Sci Rep 2024; 14:2551. [PMID: 38291135 PMCID: PMC10827726 DOI: 10.1038/s41598-024-53078-0] [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: 07/31/2023] [Accepted: 01/27/2024] [Indexed: 02/01/2024] Open
Abstract
Most patients with benign esophageal stenosis require multiple or even continuous balloon dilation treatments to achieve symptom relief. In this study, eighteen rabbits were used to establish an esophageal benign stenosis model and were divided into a control group (n = 6), a balloon group (n = 6) and a PTX-coated balloon group (n = 6) to evaluate the feasibility and effectiveness of paclitaxel (PTX)-coated balloons for the rabbit esophageal benign stenosis model. The weight and esophageal diameter were recorded every 2 weeks until 8 weeks post-surgery. Hematoxylin-eosin staining, Masson's trichrome staining and immunohistochemical staining were performed for pathological analysis. Four weeks post-operation, there was a significant difference in weight between the control group and the balloon group (p = 0.01) and between the control group and the PTX balloon group (p = 0.01). There was a significant difference in the esophageal diameter between the balloon group and the PTX balloon group at 8 weeks post-operation (p = 0.02). Four weeks post-operation, the degree of inflammatory cell infiltration in the PTX balloon group was significantly lower than that in the control group (p = 0.002) and balloon group (p = 0.001). The degree of collagen deposition in the PTX balloon group was significantly lower than that in the control group (p = 0.002) and balloon group (p = 0.03). Eight weeks post-operation, the percentage of cells positive for TGF-β (p < 0.001), the degree of inflammatory cell infiltration (p = 0.02) and the degree of collagen deposition (p = 0.02) in the PTX balloon group were significantly lower than those in the balloon group. Therefore, PTX-coated balloons may alleviate the local inflammatory response and collagen deposition when used during dilation treatment of benign esophageal stenosis.
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Affiliation(s)
- Kewei Ren
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China.
- Engineering Technology Research Center for Minimally Invasive, Interventional Tumors of Henan Province, Zhengzhou, Henan, 450052, People's Republic of China.
| | - Jianan Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Department of Interventional Radiotherapy, Zhoukou Center Hospital, Zhoukou, 46000, People's Republic of China
| | - Yahua Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Zongming Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Zihe Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Kunpeng Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Yifan Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xiaoyong Ge
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Jianzhuang Ren
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China.
- Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, 450052, People's Republic of China.
- Interventional Institute of Zhengzhou University, Zhengzhou, 450052, People's Republic of China.
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Fang JH, Li WM, He CH, Wu JL, Guo Y, Lai ZC, Li GD. Endoscopic treatment of extreme esophageal stenosis complicated with esophagotracheal fistula: A case report. World J Gastrointest Surg 2024; 16:239-247. [PMID: 38328322 PMCID: PMC10845269 DOI: 10.4240/wjgs.v16.i1.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/25/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND At present, there is no unified and effective treatment for extreme corrosive esophageal stenosis (CES) with esophagotracheal fistula (ETF). This case had extreme and severe esophageal stenosis (ES) and ETF after ingesting an enzyme-based chemical detergent, resulting in a serious pulmonary infection and severe malnutrition. Upper gastrointestinal imaging showed that he had an ETF, and endoscopy showed that he had extreme and severe esophageal stricture. This case was complex and difficult to treat. According to the domestic and foreign literature, there is no universal treatment that is low-risk. CASE SUMMARY A patient came to our hospital with extreme ES, an ETF, and severe malnutrition complicated with pulmonary tuberculosis 1 mo after the consumption of an enzyme-based detergent. The ES was serious, and the endoscope was unable to pass through the esophagus. We treated him by endoscopic incision method (EIM), esophageal stent placement (ESP), and endoscopic balloon dilation (EBD) by using the bronchoscope and gastroscope. This treatment not only closed the ETF, but also expanded the esophagus, with minimal trauma, greatly reducing the pain of the patient. According to the literature, there are no similar reported cases. CONCLUSION We report, for the first time, a patient with extreme CES complicated with ETF, where the endoscope could not be passed through his esophagus but he could be examined by bronchoscopy and treated by EIM, ESP, and EBD.
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Affiliation(s)
- Jia-Heng Fang
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Wei-Min Li
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Cheng-Hai He
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Jian-Liang Wu
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Yun Guo
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Zhi-Chao Lai
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Guo-Dong Li
- Department of Gastroenterology, Hangzhou Normal University Affiliated Hospital, Hangzhou 310000, Zhejiang Province, China
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The clinical outcomes of the radiologic method for self-expandable metal-stent placement in patients with colorectal obstruction: A prospective study. Asian J Surg 2023; 46:412-416. [PMID: 35584995 DOI: 10.1016/j.asjsur.2022.05.003] [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: 01/11/2022] [Revised: 04/21/2022] [Accepted: 05/06/2022] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To assess the clinical outcomes of self-expandable metal stent (SEMS) placement for patients with colorectal obstruction. METHODS A total of 61 patients underwent SEMS placement using computerized tomography (CT) to confirm malignancy of intrinsic origin and evaluate the exact location, notch, and extent of the disruptive laceration. RESULTS The overall technical success rate and clinical success rate of SEMS placement using the radiological method were 59 (96.7%) and 57 (93.4%), respectively. The technical success rate and clinical success rate of SEMS placement in the palliative and bridge to elective surgery (BTS) groups were 35 (97.2%), 24 (96.0%), 33 (91.7%), and 24 (96.0%). The median cumulative primary stent patency duration and patients' survival of SEMS placement was 123 days (95% CI, 65-123 days), and 133 days (95% CI, 72-133 days). The median cumulative primary stent patency duration and patient survival did not differ significantly between the palliative group 119 days; (95% CI, 59-119 days), 128 days; (95% CI, 71-128 days), and the BTS group 120 days; (95% CI, 68-120 days; p = 0.362), 130 days; (95% CI, 78-130 days); p = 0.412). CONCLUSIONS The colorectal obstruction had convoluted with curved angulation and located mainly at the rectum, sigmoid, descending colon, and the radiologic method of SEMS placement has more efficacious with a high technical and clinical success rate. However, SEMS placement was highly technical, and clinical success with median stent patency and patient survival did not differ significantly between the palliative group and the BTS group.
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Decker A, Schauer F, Lazaro A, Monasterio C, Schmidt AR, Schmitt-Graeff A, Kreisel W. Esophageal lichen planus: Current knowledge, challenges and future perspectives. World J Gastroenterol 2022; 28:5893-5909. [PMID: 36405107 PMCID: PMC9669830 DOI: 10.3748/wjg.v28.i41.5893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/17/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.
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Affiliation(s)
- Annegrit Decker
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Franziska Schauer
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79104, Germany
| | - Adhara Lazaro
- Department of Medicine, Institute of Exercise and Occupational Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Carmen Monasterio
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Arthur Robert Schmidt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Annette Schmitt-Graeff
- Institute for Dermatohistology, Pathology, and Molecular Pathology Prof. Dr. Laaf, Freiburg, Germany and: University of Freiburg, Freiburg 79106, Germany
| | - Wolfgang Kreisel
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
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6
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Palam S, Mohorek M, Rizvi S, Dua K. Clinical outcomes on weekly endoscopic dilations as the initial approach to manage patients with complex benign esophageal strictures: report on 488 dilations. Surg Endosc 2022; 36:7056-7065. [PMID: 35477807 DOI: 10.1007/s00464-022-09248-0] [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: 01/18/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Success rate of endoscopic dilation (ED) of complex benign esophageal strictures (CBES) can be as low as 65%. Since EDs are usually performed at 2-4-week intervals, the aim of this study was to evaluate the clinical outcomes of EDs done initially at weekly intervals. METHODS A cohort of patients with CBES (luminal diameter < 10 mm) underwent ED at weekly intervals and subsequent dilation intervals adjusted based on response. Weekly EDs were also re-initiated in those requiring additional interventions (electro-cautery/stents). Group A patients: Failed prior EDs done at ≥ 2-week intervals. Group B: CBES with no prior dilations. Success was defined as achieving and maintaining a luminal diameter of ≥ 14 mm and patient remaining dysphagia-free with minimal re-interventions. RESULTS 488 EDs were performed on a cohort of 57 consecutive patients with CBES. Median follow-up was 4 years. Group A: 21 patients (mean age 65 ± 13 years; mean interval between prior failed dilations 17 ± 9 days). 57% of these patients achieved long-term success with weekly dilations (mean 8 ± 4.7 dilations/patient). Group B: 36 patients (mean age 61 ± 13 years, mean 6.5 ± 5.5 dilations/patient). Long-term success was 83.3% (P = 0.033). Despite weekly dilations, unable to achieve a diameter of 14 mm in 5 patients. AE: perforation 1 (0.2%), bleeding 1 (0.2%). CONCLUSION Significant proportion of patients with CBES who failed prior dilations done at ≥ 2-week intervals achieved dysphagia-free status by initiating weekly dilations. Hence, before considering other options (electro-cautery/stents), one can consider using this approach. This approach can also be used upfront in patients with newly diagnosed CBES.
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Affiliation(s)
- Sowmya Palam
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mathew Mohorek
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Syed Rizvi
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kulwinder Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA.
- Graduate School of Biomedical Sciences, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
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7
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Zhang F, Xu J, Zhu Y, Shi Y, Wu B, Wang H, Huang C. Endoscopic ultrasonography guided cutting scar of esophageal stricture after endoscopic injection sclerotherapy. BMC Gastroenterol 2022; 22:343. [PMID: 35840909 PMCID: PMC9284865 DOI: 10.1186/s12876-022-02420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate efficacy and safety of endoscopic ultrasonography (EUS) guiding to cut the scar of esophageal stricture after endoscopic injection sclerotherapy (EIS). METHODS The data of 10 patients with oesophageal stricture after esophageal varices EIS in our hospital from September 1, 2021 to December 31, 2021 treated by cutting the scar guided by ultrasonic endoscopy were retrospective, and the efficacy was evaluated. RESULTS The dysphagia was obviously relieved in 9 patients during follow-up, and 1 patient suffered dysphagia again after the treatment. There was no complications of perforation, bleeding and infection among the paitents. CONCLUSION EUS guiding to cut the scar of esophageal stricture after EIS was safe and reliable.
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Affiliation(s)
- Fulong Zhang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Jing Xu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Yuandong Zhu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China.
| | - Yan Shi
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Bo Wu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Hai Wang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Chaojun Huang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
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Predictive factors for the success of endoscopic dilation of esophageal caustic stricture: the experience of a French tertiary reference center. Surg Endosc 2022; 36:5660-5668. [PMID: 35790591 DOI: 10.1007/s00464-021-08781-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Predictors of the efficacy of endoscopic dilation for caustic esophageal stricture have been poorly studied. METHODS All patients undergoing an endoscopic dilation for an esophageal caustic stricture between 1990 and 2015 in a French national reference center were included. Success of dilation was defined by self-food autonomy without the need for reconstructive esophageal surgery. RESULTS During the study period, 894 patients were admitted after caustic ingestion. Among them, 101 patients developed esophageal stricture and 92 patients were eligible for analysis (missing data in 8 cases, 1 patient died before endoscopic dilation). In this cohort (median age 42 years, women 53%, strong alkali 74%, suicide attempt 77%, hydrostatic balloon use 93%), the overall success rate of dilation was 57% with a median number of 3 dilation sessions (274 sessions, range 1-17). Factors predicting the success of the procedure were: non-inflammatory stricture or non-inflammatory intercalated mucosa between stricture (88% vs 47%, p = 0.001), a single stricture versus 2 or more strictures (69% vs 47% vs 33%, respectively, p = 0.04), a stricture of less than 5 cm (70% vs 27%, p < 0.001) and the existence of mild/ moderately tight or very tight stricture (70% vs 21% of success, p < 0.001). Perforation rate was 6.5% (18/274) requiring emergency surgery in 2 cases. CONCLUSION Several characteristics of caustic esophageal strictures are significantly associated with the success rate of endoscopic dilation. Our data may be useful for customizing treatment strategies in patients with a caustic stricture.
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Xu XY, Geng ZH, Chen TY, Li QL, Cai MY, Xu JX, Zhang DF, Hu JW, Zhou PH. Submucosal tunneling endoscopic biopsy and myotomy for management of unknown esophageal stenosis. Gastroenterol Rep (Oxf) 2022; 10:goac021. [PMID: 35663150 PMCID: PMC9155210 DOI: 10.1093/gastro/goac021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/20/2022] [Indexed: 02/06/2023] Open
Affiliation(s)
- Xiao-Yue Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Zi-Han Geng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Tian-Yin Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Jia-Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Dan-Feng Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, P. R. China
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10
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Ball E, Chase D, Coomer A. Treatment of acute traumatic nasopharyngeal stenosis with balloon dilation in two dogs. N Z Vet J 2022; 70:279-286. [PMID: 35506314 DOI: 10.1080/00480169.2022.2073918] [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: 10/18/2022]
Abstract
CASE HISTORY Two dogs were referred to Veterinary Specialists Aotearoa for evaluation and treatment after sustaining significant head trauma. Case 1 was a 7-month-old, female Staffordshire Bull Terrier who was hit by a car at low speed. Case 2 was a 2-year old, male neutered German Shepherd who sustained a gunshot wound to the head whilst on duty for the New Zealand Police Dog Unit. CLINICAL FINDINGS The dog in Case 1 suffered numerous facial fractures which caused collapse of the ventral nasal meatus and dorsal nasopharyngeal wall. The dog in Case 2 had extensive osseous and soft tissue damage to the nose, nasopharynx and cervical region with severe narrowing of the ventral meatuses, nasopharyngeal meatus and rostral nasopharynx due to multiple fracture fragments and shrapnel pieces. A diagnosis of traumatic nasopharyngeal stenosis was made in each case by computed tomography. Mechanical balloon dilation was used to treat the stenosis in both dogs. The balloon dilations were performed using a 12-mm balloon dilation catheter inserted in an antegrade fashion. In the first dog, the procedure was performed blind and was repeated three times with 5 and 9-day intervals between dilations. In the second dog, the procedure was performed under endoscopic guidance and again, was repeated three times with a 7-day interval between dilations. Clinical success was reported in both patients following treatment and the second dog also underwent a follow-up computed tomography scan which confirmed resolution of the stenosis. DIAGNOSIS Traumatic nasopharyngeal stenosis that was successfully treated with balloon dilation. CLINICAL RELEVANCE Findings suggest that balloon dilation may be an effective technique for the treatment of traumatic nasopharyngeal stenosis in dogs. Multiple dilation procedures are likely required, but the procedure can ultimately result in long term clinical resolution.
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Affiliation(s)
- E Ball
- Veterinary Specialists Aotearoa, Mount Albert, Auckland, New Zealand
| | - D Chase
- Veterinary Specialists Aotearoa, Mount Albert, Auckland, New Zealand
| | - A Coomer
- Veterinary Specialists Aotearoa, Mount Albert, Auckland, New Zealand
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11
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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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12
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Xu Z, Huang T, Pan M, Huang Y, Jiang Y. Case Report: Recessive Dystrophic Epidermolysis Bullosa With Severe Esophageal Stenosis: A Case Report and Literature Review. Br J Biomed Sci 2022; 79:10200. [PMID: 35996499 PMCID: PMC9302543 DOI: 10.3389/bjbs.2022.10200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/28/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Zhen Xu
- Deparment of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tianqiao Huang
- Deparment of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Min Pan
- Deparment of Dermatology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yichuan Huang
- Deparment of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Jiang
- Deparment of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Yan Jiang,
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Endoscopic Management of Refractory Benign Esophageal Strictures. Dysphagia 2021; 36:504-516. [PMID: 33710389 DOI: 10.1007/s00455-021-10270-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.
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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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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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Abstract
IMPORTANCE Gastroesophageal reflux disease (GERD) is defined by recurrent and troublesome heartburn and regurgitation or GERD-specific complications and affects approximately 20% of the adult population in high-income countries. OBSERVATIONS GERD can influence patients' health-related quality of life and is associated with an increased risk of esophagitis, esophageal strictures, Barrett esophagus, and esophageal adenocarcinoma. Obesity, tobacco smoking, and genetic predisposition increase the risk of developing GERD. Typical GERD symptoms are often sufficient to determine the diagnosis, but less common symptoms and signs, such as dysphagia and chronic cough, may occur. Patients with typical GERD symptoms can be medicated empirically with a proton pump inhibitor (PPI). Among patients who do not respond to such treatment or if the diagnosis is unclear, endoscopy, esophageal manometry, and esophageal pH monitoring are recommended. Patients with GERD symptoms combined with warning symptoms of malignancy (eg, dysphagia, weight loss, bleeding) and those with other main risk factors for esophageal adenocarcinoma, such as older age, male sex, and obesity, should undergo endoscopy. Lifestyle changes, medication, and surgery are the main treatment options for GERD. Weight loss and smoking cessation are often useful. Medication with a PPI is the most common treatment, and after initial full-dose therapy, which usually is omeprazole 20 mg once daily, the aim is to use the lowest effective dose. Observational studies have suggested several adverse effects after long-term PPI, but these findings need to be confirmed before influencing clinical decision making. Surgery with laparoscopic fundoplication is an invasive treatment alternative in select patients after thorough and objective assessments, particularly if they are young and healthy. Endoscopic and less invasive surgical techniques are emerging, which may reduce the use of long-term PPI and fundoplication, but the long-term safety and efficacy remain to be scientifically established. CONCLUSIONS AND RELEVANCE The clinical management of GERD influences the lives of many individuals and is responsible for substantial consumption of health care and societal resources. Treatments include lifestyle modification, PPI medication, and laparoscopic fundoplication. New endoscopic and less invasive surgical procedures are evolving. PPI use remains the dominant treatment, but long-term therapy requires follow-up and reevaluation for potential adverse effects.
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Affiliation(s)
- John Maret-Ouda
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Eskilstuna, Sweden
| | - Sheraz R Markar
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
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Santos S, Simões G, Lemos J, Saiote J, Loureiro R, Seves I. Long-Term Self-Expandable Metal Stent (SEMS) for Esophageal Variceal Bleeding: A Picture of the Natural History. Am J Gastroenterol 2020; 115:1915-1917. [PMID: 33156112 DOI: 10.14309/ajg.0000000000000802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We aim to discuss the utility of self-expandable esophageal metal stent (SEMS) in variceal bleeding in challenging cases. METHODS Case description, discussion on patient management and decision-making process in an uncommon situation, from a multidisciplinary point of view. RESULTS We report a case of a cirrhotic patient with refractory variceal bleeding who underwent a SEMS placement, which remained in situ for 9 months. This decision was based on the initial poor status and short life expectancy, limiting the consideration of other options for lowering portal hypertension, along with an underlying prothrombotic predisposition. However, the patient's general and hepatic improvement and the development of dysphagia led to the SEMS removal, exposing a large esophageal-tracheal fistula. DISCUSSION Early patient evaluation, risks of long-term SEMS, and life expectancy should be taken in consideration before SEMS placement.
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Affiliation(s)
- Sara Santos
- Gastroenterology Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Guilherme Simões
- Gastroenterology Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Joana Lemos
- Gastroenterology Unit, Instituto Português de Oncologia de Lisboa, Lisbon, Portugal
| | - Joana Saiote
- Gastroenterology Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Rafaela Loureiro
- Gastroenterology Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Isabel Seves
- Gastroenterology Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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Daniel P, Samanta J, Gulati A, Gupta P, Muktesh G, Sinha SK, Kochhar R. Can high-frequency mini-probe endoscopic ultrasonography predict outcome of endoscopic dilation in patients with benign esophageal strictures? Endosc Int Open 2020; 8:E1371-E1378. [PMID: 33015340 PMCID: PMC7508664 DOI: 10.1055/a-1223-1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/08/2020] [Indexed: 11/22/2022] Open
Abstract
Background and study aims Endoscopic dilation is first-line management for benign esophageal strictures (ES). Depth of involvement of the esophageal wall on endosonography using high frequency mini-probe (EUS-M) may predict response to dilation. This study evaluated EUS-M characteristics to predict response of ES to endoscopic dilation. Patients and methods EUS-M was used to measure the total esophageal wall thickness (EWT), involved EWT, percentage of involved wall and layers of wall involved in consecutive patients of benign ES. After a maximum of five sessions of endoscopic dilation, the cohort was divided into responders and refractory strictures. EUS-M characteristics were compared for underlying etiology as also between responders and refractory strictures. Results Of the 30 strictures (17 females, age: 47.16 ± 15.86 yrs.) 13 were anastomotic, eight corrosive, seven peptic and 2 others. Corrosive strictures had the highest involved EWT and percentage of involved wall (3.51 ± 1.36 mm; 76.38 %) followed by anastomotic (2.73 ± 1.7 mm; 65.54 %) and peptic (1.39 ± 0.62 mm; 40.71 %) ( P = 0.026 and 0.021 respectively). After five dilations, 22 were classified as responders and eight as refractory. Wall involvement > 70 % had a greater proportion of refractory strictures ( P = 0.019). Strictures with involved EWT of ≥ 2.85 mm required more dilations ( P = 0.011). Fewer dilations were required for stricture resolution with only mucosal involvement compared to deeper involvement such as submucosa and muscularis propria (2.14 vs. 5.80; P = 0.001). Conclusion EUS-M evaluation shows that corrosive and anastomotic strictures have greater depth of involvement compared to peptic strictures. Depth of esophageal wall involvement in a stricture predicts response to dilation.
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Affiliation(s)
- Philip Daniel
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gulati
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Muktesh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K. Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Flexible endoscopic strategies for the difficult esophageal stricture. Curr Opin Gastroenterol 2020; 36:379-384. [PMID: 32618615 DOI: 10.1097/mog.0000000000000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Benign strictures of the esophagus, caused by various causes, are frequently encountered in clinical practice. Although endoscopic dilation is still the standard and first-line therapy, complex and difficult esophageal strictures are still encountered and remain a challenge to endoscopists. The main scope of this review article is to offer a closer look at the different endoscopic modalities and approaches to complex and difficult esophageal strictures. RECENT FINDINGS In the past few years, endoscopic dilatation, stents including self-expandable and biodegradable types, incisional therapy, and pharmacological treatments have been utilized in the prevention and management of refractory and recurrent esophageal strictures. Meanwhile, more recent techniques such as the BougieCap, percutaneous transgastric endoscopic myotomy, through-the-scope stents, radial incision and cutting, etc. have been developed as alternative methods. A number of studies utilizing these newer methods have shown promising results in the treatment of complex and difficult esophageal strictures. SUMMARY Endoscopic treatment of refractory, complex and difficult esophageal strictures still remains to be a challenge for many endoscopists. While balloon or bougie dilatation still remains to be the first-line approach, other techniques have emerged as treatment alternatives and may become adjunct therapy to endoscopic dilatation.
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Rana SS, Sharma R, Kishore K, Gupta R. High-frequency miniprobe endoscopic ultrasonography in the management of benign esophageal strictures. Ann Gastroenterol 2020; 33:25-29. [PMID: 31892794 PMCID: PMC6928478 DOI: 10.20524/aog.2019.0436] [Citation(s) in RCA: 5] [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: 08/26/2019] [Accepted: 11/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background Endoscopic ultrasonography (EUS) can predict the response to endoscopic dilatation by delineating the extent of esophageal wall involvement in benign strictures. In contrast to conventional echoendoscopes, the EUS miniprobe can be negotiated across the stricture and thus provide more information. This study retrospectively evaluated the role of miniprobe EUS in predicting the response to endoscopic dilatation in benign esophageal strictures. Methods We analyzed the records of 24 patients (mean age: 48.1±17.9 years) with benign esophageal strictures (corrosive 11, peptic 5, post-radiation 3, anastomotic 2, and others 3) who underwent miniprobe EUS prior to endoscopic dilatation. Results The stricture was located in the upper, middle and lower esophagus in 2, 9 and 13 patients, respectively. The mean length of the stricture was 3.4±1.9 cm. Miniprobe EUS was able to examine the stricture completely in all patients. The mucosa was involved in 6, mucosa and submucosa in 4, and mucosa, submucosa and muscularis propria in 14 patients. The mean maximum wall thickness of esophageal wall on EUS at the level of the stricture was 8.2±2.8 mm. The mean number of sessions required to achieve adequate dilation was 4.7±2.6. Patients with mucosal involvement required significantly fewer endoscopic sessions for adequate dilatation as compared to patients with muscularis propria involvement (1.8 vs. 6.2 sessions, respectively; P=0.0002). Patients with greater esophageal wall thickness required more endoscopic sessions (r=0.737) (P=0.00004). Conclusion Miniprobe EUS, by delineating the extent of wall involvement as well as measuring wall thickness in benign esophageal strictures, can predict the response to endoscopic dilatation.
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Affiliation(s)
| | - Ravi Sharma
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma)
| | | | - Rajesh Gupta
- Department of Surgery (Rajesh Gupta), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Short-term Effects of Mitomycin C Infiltration for Caustic Oesophageal Strictures in Children. J Pediatr Gastroenterol Nutr 2019; 69:673-677. [PMID: 31436706 DOI: 10.1097/mpg.0000000000002466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the efficacy and safety of endoscopic local infiltration of mitomycin C (MMC) after oesophageal dilation for children suffering from refractory postcorrosive oesophageal stricture (OS). METHODS Children referred to Cairo University Specialized Paediatric Hospital with refractory postcorrosive OS during the period from March 2016 to August 2017 were included in this study. MMC was infiltrated endoscopically at the stricture site by the end of the dilation session. The measured outcomes were dysphagia score (DS) and periodic dilation index (PDI). RESULTS During the inclusion period of the presented study, 17 children met the inclusion criteria. There were 7 boys and 10 girls. During the follow-up period, an average of 3.8 dilation sessions with MMC infiltration per case were performed, using a total dose of 1 mg each session. The median follow-up period was 9.5 months. The median DS improved from DS 3 before application of MMC to DS 0 at the last follow-up (P < 0.001). Additionally, the median PDI declined from 1 to 0.75 after MMC application (P = 0.052). Sixteen cases (94%) became dysphagia free after 6 months. Seven patients experienced postdilation minor bleeding that was spontaneously resolved, not triggering blood transfusion. There were no infiltration-related complications in the included series. CONCLUSION Stricture-site MMC endoscopic infiltration by the end of a dilation session proved to be safe and effective in improving the DS and PDI.
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Yang K, Cao J, Yuan TW, Zhu YQ, Zhou B, Cheng YS. Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model. World J Gastroenterol 2019; 25:3207-3217. [PMID: 31333312 PMCID: PMC6626718 DOI: 10.3748/wjg.v25.i25.3207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures (BES). Magnesium alloy stents are a good candidate because of biological safety, but show a poor corrosion resistance and a quick loss of mechanical support in vivo.
AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent.
METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance (stent group). The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models (control group). Esophagography was performed at 1, 2, and 3 weeks. Four, six, and five rabbits in the stent group and two rabbits in the control groups were euthanized, respectively, at each time point for histological examination.
RESULTS All stent insertions were well tolerated. The esophageal diameters at immediately, 1, 2 and 3 wk were 9.8 ± 0.3 mm, 9.7 ± 0.7 mm, 9.4 ± 0.8 mm, and 9.2 ± 0.5 mm, respectively (vs 4.9 ± 0.3 mm before stent insertion; P < 0.05). Magnesium stents migrated in eight rabbits [one at 1 wk (1/15), three at 2 wk (3/11), and four at 3 wk (4/5)]. Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was found significantly thinner in the stent group than in the control group (P < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits (P > 0.05).
CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction. Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.
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Affiliation(s)
- Kai Yang
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Jun Cao
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Tian-Wen Yuan
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Yue-Qi Zhu
- Department of Radiological Intervention, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
| | - Bi Zhou
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Ying-Sheng Cheng
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
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Yan X, Nie D, Zhang Y, Chang H, Huang Y. Effectiveness of an orally administered steroid gel at preventing restenosis after endoscopic balloon dilation of benign esophageal stricture. Medicine (Baltimore) 2019; 98:e14565. [PMID: 30813172 PMCID: PMC6407972 DOI: 10.1097/md.0000000000014565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Restenosis occurs in 10% to 30% of patients after endoscopic balloon dilation (EBD) of benign esophageal stricture. This study aimed to investigate whether an orally administered steroid/gel mixture would inhibit restenosis after EBD for benign esophageal stricture. METHODS This retrospective analysis included patients with benign esophageal stricture treated with EBD at the Peking University Third Hospital, China (September 2005 to October 2017). The patients were divided into an EBD alone group (EBD only) and EBD/OHA group (EBD plus oral hydrocortisone sodium succinate/aluminum phosphate gel mixture). Patients were followed-up for 3 months. EBD was repeated for persistent dysphagia. The outcome measures included the restenosis rate and the number of additional EBD sessions required during follow-up. Any side effects were noted. RESULTS Thirty-two patients were included (EBD alone group, n = 12; EBD/OHA group, n = 20). Baseline demographic and clinical characteristics (including age, sex, etiology, stricture location, and diameter of narrowest segment) did not differ between groups. Restenosis rate was significantly lower in the EBD/OHA group than in the EBD alone group (5/20, 25.0% vs 8/12, 66.7%; P = .025). The median number of EBD sessions required was numerically lower in the EBD/OHA group (median, 1.0; interquartile range, 1.0-1.8) than in the EBD alone group (median 2.0, interquartile ranged 1.0-2.5), but statistical significance was not attained (P = .071). The only side effects occurred in the EBD/OHA group: hypokalemia in 4/20 (20.0%) and apathy/somnolence in 1/20 (5.0%). CONCLUSIONS An orally administered steroid/gel mixture might reduce the incidence of restenosis after EBD for benign esophageal stricture, but it requires confirmation by prospective trials.
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Endoscopic Dilation with Bougies versus Balloon Dilation in Esophageal Benign Strictures: Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2018; 2018:5874870. [PMID: 30116265 PMCID: PMC6079446 DOI: 10.1155/2018/5874870] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/05/2018] [Indexed: 12/23/2022] Open
Abstract
Background The use of bougies and balloons to dilate benign esophageal strictures (BES) is a consolidated procedure. However, the amount of evidence available in scientific literature supporting which is the best technique is very low, despite the great prevalence and importance of such pathology. This systematic review with meta-analysis aims at comparing both techniques, providing good quality of evidence. Methods We searched for randomized clinical trials (RCTs) published from insertion to November 2017, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, and grey literature. After the data extraction, a meta-analysis was performed. The main outcomes were symptomatic relief and recurrence rate. The secondary outcomes were bleeding, perforation, and postprocedure pain. Results We included 5 randomized clinical trials (RCTs), totalizing 461 patients. Among them, 151 were treated with bougie dilation and 225 underwent balloon dilation. Regarding symptomatic relief, recurrence, bleeding, and perforation rates, there were no differences between the methods. Concerning postprocedure pain, patients submitted to balloon dilation had less intense pain (RD 0.27, 95% IC -0.42 to -0.07, P = 0.007). Conclusion We conclude that there is no difference between bougie and balloon dilation of BESs regarding symptomatic relief, recurrence rate at 12 months, bleeding, and perforation. Patients undergoing balloon dilation present less severe postprocedure pain.
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Heading RC. Editorial: self-dilation for refractory oesophageal strictures is worth considering. Aliment Pharmacol Ther 2018; 48:230-231. [PMID: 29939418 DOI: 10.1111/apt.14838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Szapáry L, Tinusz B, Farkas N, Márta K, Szakó L, Meczker Á, Hágendorn R, Bajor J, Vincze Á, Gyöngyi Z, Mikó A, Csupor D, Hegyi P, Erőss B. Intralesional steroid is beneficial in benign refractory esophageal strictures: A meta-analysis. World J Gastroenterol 2018; 24:2311-2319. [PMID: 29881240 PMCID: PMC5989245 DOI: 10.3748/wjg.v24.i21.2311] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the effect of intralesional steroid injections in addition to endoscopic dilation of benign refractory esophageal strictures. METHODS A comprehensive search was performed in three databases from inception to 10 April 2017 to identify trials, comparing the efficacy of endoscopic dilation to dilation combined with intralesional steroid injections. Following the data extraction, meta-analytical calculations were performed on measures of outcome by the random-effects method of DerSimonian and Laird. Heterogeneity of the studies was tested by Cochrane's Q and I2 statistics. Risk of quality and bias was assessed by the Newcastle Ottawa Scale and JADAD assessment tools. RESULTS Eleven articles were identified suitable for analyses, involving 343 patients, 235 cases and 229 controls in total. Four studies used crossover design with 121 subjects enrolled. The periodic dilation index (PDI) was comparable in 4 studies, where the pooled result showed a significant improvement of PDI in the steroid group (MD: -1.12 dilation/month, 95%CI: -1.99 to -0.25 P = 0.012; I2 = 74.4%). The total number of repeat dilations (TNRD) was comparable in 5 studies and showed a non-significant decrease (MD: -1.17, 95%CI: -0.24-0.05, P = 0.057; I2 = 0), while the dysphagia score (DS) was comparable in 5 studies and did not improve (SMD: 0.35, 95%CI: -0.38, 1.08, P = 0.351; I2 = 83.98%) after intralesional steroid injection. CONCLUSION Intralesional steroid injection increases the time between endoscopic dilations of benign refractory esophageal strictures. However, its potential role needs further research.
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Affiliation(s)
- László Szapáry
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Benedek Tinusz
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Ágnes Meczker
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Roland Hágendorn
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Judit Bajor
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Dezső Csupor
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
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Martins D, Pires S, Pimentel-Nunes P, Almeida Silva R, Dias CC, Dinis-Ribeiro M. Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:291-298. [PMID: 30480046 DOI: 10.1159/000486608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/04/2018] [Indexed: 12/19/2022]
Abstract
Background/Aims Dysphagia due to benign pharyngoesophageal strictures (PES) often requires repeated dilations; however, a uniform definition for the therapeutic efficacy of this technique has not been yet established. We aimed to assess the overall efficacy of endoscopic dilation of pharyngoesophageal anastomotic or post-radiotherapy (post-RT) strictures. Methods The data of 48 patients with post-RT (n = 29) or anastomotic PES (n = 19) submitted to endoscopic dilation during a 3-year period were retrospectively assessed. The Kochman criteria were used to determine refractoriness and recurrence. Patients were asked to answer a questionnaire determining prospectively the dilation program efficacy as (a) dysphagia improvement, (b) dysphagia resolution, (c) need for further dilations, or (d) percutaneous endoscopic gastrostomy (PEG) during the previous 6 months. Need for additional therapy was considered an inefficacy criterion. Results The median number of dilations per patient was 4 (total of 296 dilations) with a median follow-up of 29 months. The mean predilation dysphagia Mellow-Pinkas score was 3 and the initial stenosis diameter was 7 mm. Fifteen and 29% of patients presented with the Kochman criteria for refractory and recurrent strictures, respectively. Moreover, 96 and 60% showed dysphagia improvement and resolution, respectively. Seventy-five-percent did not require dilations during 6 months, and 89% did not require PEG. From the patients' perspective, overall efficacy was achieved in 58% of cases. Nine additional therapies were required. Number of dilations (OR 0.7), stricture diameter (OR 2.2), and nonrecurrence criteria (OR 14.2) appeared as significant predictors of overall efficacy, whereas refractory stenosis criteria did not. Conclusions Endoscopic dilation seems to be effective for patients with dysphagia after RT or surgery, especially when assessed as patient perception of improvement. Narrow strictures, recurrent ones, and strictures requiring a higher number of dilations may predict worse outcomes. Key Message Health professionals should establish well-defined efficacy criteria for dilations and base their decision beyond exclusively objective measurements.
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Affiliation(s)
- Diana Martins
- Gastroenterology Department, Tondela-Viseu Hospital Center, Viseu, Portugal
| | - Sara Pires
- Gastroenterology Department, Espirito Santo Hospital, Évora, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Almeida Silva
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Claúdia Camila Dias
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,Department of Community Medicine, Information and Decision in Health, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
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Shipley LC, Al Momani LA, Locke A, Young M. Lymphocytic Esophagitis: A Rare Disease on the Rise. Cureus 2018; 10:e2153. [PMID: 29637034 PMCID: PMC5884572 DOI: 10.7759/cureus.2153] [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] [Indexed: 11/27/2022] Open
Abstract
Lymphocytic esophagitis is a rare, poorly understood disease. This case report presents a patient with a history of squamous cell carcinoma of the tongue who presented with dysphagia. He received esophageal dilation that unfortunately resulted in perforation. Biopsies showed lymphocytic esophagitis. There are very few cases in the literature describing perforation in lymphocytic esophagitis. In addition, management and treatment have been challenging for physicians; however, this case represents a complete symptomatic improvement in four to six weeks with a proton pump inhibitor.
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Affiliation(s)
- Lindsey C Shipley
- Internal Medicine, Quillen College of Medicine, East Tennessee State University
| | | | - Allison Locke
- ETSU Gastroenterology, East Tennessee State University
| | - Mark Young
- Gastroenterology Associates of Northeast Tennessee, East Tennessee State University
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Strong EB, Randall DR, Cates DJ, Belafsky PC. Analysis of Reported Balloon Malfunctions and Proposed Rescue Strategy for Malfunction during Airway Dilation. Otolaryngol Head Neck Surg 2017; 158:331-336. [PMID: 29232174 DOI: 10.1177/0194599817742356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective The rate of balloon dilator failure is unknown, and a rescue strategy for device malfunction has not been established. The purposes of this investigation were to determine the approximate number of balloon failures in the gastrointestinal tract and airway, evaluate the parameters required to rupture balloon dilators, and develop a rescue strategy to efficiently reestablish airway patency. Study Design Retrospective cohort and basic medical research. Setting Academic tertiary care medical center. Subjects and Methods The Manufacturer and User Facility Device Experience database was queried for adverse events associated with tracheal and esophageal dilators between January 1, 2014, and January 1, 2017. A bench-top model of airway stenosis was developed, and optimal conditions for the safe removal of a malfunctioning dilator were assessed (2, 4, 6 atm). Results There were 420 reported balloon malfunctions, including 104 cases with deflation/removal issues. The bench-top model determined that device rupture allowing for immediate removal occurs with needle puncture at balloon pressures ≥8 atm. Balloons inflated to 6 atm required a median of 17.5 seconds (range, 0-55.3) for removal, in comparison with 30.2 seconds (range, 7.1-87.5) at 2 atm ( P > .05). Conclusion Balloon dilator malfunction is a significant problem that practitioners must be prepared for. Pressure ≥8 atm (~33% overinflation) is required to consistently cause complete balloon dilator rupture via needle puncture. While counterintuitive, increasing the inflation pressure of a malfunctioning balloon (8-10 atm) may expedite rupture and safe removal. A rescue strategy for balloon malfunction is proposed.
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Affiliation(s)
- E Brandon Strong
- 1 Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Sacramento, California, USA.,2 Department of Biological Sciences, California Polytechnic State University, San Luis Obispo, California, USA
| | - Derrick R Randall
- 1 Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Sacramento, California, USA.,3 Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Daniel J Cates
- 1 Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Sacramento, California, USA
| | - Peter C Belafsky
- 1 Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Sacramento, California, USA
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Abstract
OPINION STATEMENT Dysphagia is a common problem in the elderly population with an especially high prevalence in hospitalized and institutionalized patients. If inadequately addressed, dysphagia leads to significant morbidity and contributes to decreased quality of life. Dysphagia can be categorized as emanating from either an oropharyngeal or esophageal process. A disproportionate number of elderly patients suffer from oropharyngeal dysphagia with a multifactorial etiology. Historically, treatment options have been limited and included mostly supportive care with a focus on dietary modification, food avoidance, and swallow rehabilitation. Nascent technologies such as the functional luminal imaging probe (FLIP) and advances in esophageal manometry are improving our understanding of the pathophysiology of oropharyngeal dysphagia. Recent developments in the treatment of specific causes of oropharyngeal dysphagia, including endoscopic balloon dilations for upper esophageal sphincter (UES) dysfunction, show promise and are expected to enhance with further research. Esophageal dysphagia is also common in the elderly and more commonly due to an identifiable cause. The full breadth of treatment options is frequently unavailable to elderly patients due to comorbidities and overall functional status. However, the increasing availability of less invasive solutions to specific esophageal pathologies has augmented the number of treatment options available to this population, where an individualized approach to patient care is paramount. This review focuses on the evaluation and management of dysphagia in the elderly and delineates how standard and novel therapeutics are contributing to more nuanced and personalized management.
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Affiliation(s)
- Scott M Smukalla
- Department of Gastroenterology, Center for Esophageal Disease, NYU School of Medicine, 240 East 38th St., 23rd Floor, New York, NY, 10016, USA
| | - Irina Dimitrova
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | | | - Abraham Khan
- Department of Gastroenterology, Center for Esophageal Disease, NYU School of Medicine, 240 East 38th St., 23rd Floor, New York, NY, 10016, USA.
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Tambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V, Contini AC, Romeo E, Rea F, Faraci S, Federici di Abriola G, Dall'Oglio L. Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures. Front Pediatr 2017; 5:120. [PMID: 28611969 PMCID: PMC5447026 DOI: 10.3389/fped.2017.00120] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/04/2017] [Indexed: 01/10/2023] Open
Abstract
Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,University of L'Aquila, L'Aquila, Italy
| | - Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Filippo Torroni
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Contini
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Erminia Romeo
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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