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Imaoka K, Harano M, Oshita K, Yano T, Kubota T, Yoshimitsu M, Nakano K, Idan H, Shiozaki S, Okajima M. Indocyanine green fluorescence imaging for subtotal esophagectomy due to esophageal stenosis after acute esophageal necrosis: a report of two cases. Clin J Gastroenterol 2021; 14:415-421. [PMID: 33481163 DOI: 10.1007/s12328-020-01326-x] [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] [Received: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Abstract
Although esophageal stricture after acute esophageal necrosis (AEN) is often refractory to dilation therapy, there have been few reports of surgical intervention. We report two rare cases of successful subtotal esophagectomy and esophagogastrostomy for esophageal strictures after AEN using indocyanine green (ICG) fluorescence imaging. In case 1, emergent esophagogastroduodenoscopy (EGD) in a 56-year-old man with coffee-ground emesis revealed black esophageal mucosa in the middle to lower esophagus, indicating AEN. Despite conservative therapy, an esophageal stricture developed after 2 weeks. Repeated endoscopic balloon dilation (EBD) did not resolve the stenosis; esophagectomy was thus performed approximately 6 months after AEN onset. We evaluated the blood flow to the esophagus using ICG fluorescence imaging to determine the proximal surgical resection line. The postoperative course was uneventful. In case 2, an 81-year-old woman with upper gastrointestinal bleeding with hematemesis and chest pain was diagnosed with AEN by EGD and was treated with conservative therapy. An esophageal stricture developed after 3 weeks, and repeated EBD was ineffective. Approximately 2 months after AEN onset, she underwent esophagectomy using ICG fluorescence imaging. The postoperative course was uneventful. Considering that AEN is a blood flow disorder, ICG fluorescence imaging is a useful technology to prevent surgical morbidity.
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Affiliation(s)
- Kouki Imaoka
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.,Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Masao Harano
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.
| | - Ko Oshita
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Takuya Yano
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Tetsushi Kubota
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Masanori Yoshimitsu
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Kanyu Nakano
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Hitoshi Idan
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Shigehiro Shiozaki
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Masazumi Okajima
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.,Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Gurvits GE. Nuances in diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2020; 33:440-441. [PMID: 32624671 PMCID: PMC7315703 DOI: 10.20524/aog.2020.0488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Grigoriy E Gurvits
- Department of Medicine, Division of Gastroenterology, New York University School of Medicine/Langone Medical Center, NY, USA
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Acute Esophageal Necrosis in a Patient With Prostate Cancer Postchemotherapy. ACG Case Rep J 2020; 7:e00366. [PMID: 32548194 PMCID: PMC7224703 DOI: 10.14309/crj.0000000000000366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/12/2020] [Indexed: 11/17/2022] Open
Abstract
Acute esophageal necrosis (AEN) describes a potentially irreversible injury to esophageal mucosa secondary to vascular hypoperfusion. An 84-year-old man was admitted for the correction of a displaced nephrostomy tube and management of acute kidney injury. During his stay, the patient developed odynophagia and acute gastrointestinal hemorrhage. Despite mild initial symptoms, diffuse circumferential black esophageal mucosa was visualized on endoscopy, and a diagnosis of AEN was made. This unique case highlights the association between AEN and leukopenia, vascular disease, hypercoagulability, and infection. Presentations such as this patient should prompt the physicians' consideration of this differential earlier.
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Schizas D, Theochari NA, Mylonas KS, Kanavidis P, Spartalis E, Triantafyllou S, Economopoulos KP, Theodorou D, Liakakos T. Acute esophageal necrosis: A systematic review and pooled analysis. World J Gastrointest Surg 2020; 12:104-115. [PMID: 32218893 PMCID: PMC7061242 DOI: 10.4240/wjgs.v12.i3.104] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute esophageal necrosis (AEN) is a rare entity with multifactorial etiology, usually presenting with signs of upper gastrointestinal bleeding.
AIM To systematically review all available data on demographics, clinical features, outcomes and management of this medical condition.
METHODS A systematic literature search was performed with respect to the PRISMA statement (end-of-search date: October 24, 2018). Data on the study design, interventions, participants and outcomes were extracted by two independent reviewers.
RESULTS Seventy-nine studies were included in this review. Overall, 114 patients with AEN were identified, of whom 83 were males and 31 females. Mean patient age was 62.1 ± 16.1. The most common presenting symptoms were melena, hematemesis or other manifestations of gastric bleeding (85%). The lower esophagus was most commonly involved (92.9%). The most widely implemented treatment modality was conservative treatment (75.4%), while surgical or endoscopic intervention was required in 24.6% of the cases. Mean overall follow-up was 66.2 ± 101.8 d. Overall 29.9% of patients died either during the initial hospital stay or during the follow-up period. Gastrointestinal symptoms on presentation [Odds ratio 3.50 (1.09-11.30), P = 0.03] and need for surgical or endoscopic treatment [surgical: Odds ratio 1.25 (1.03-1.51), P = 0.02; endoscopic: Odds ratio 1.4 (1.17-1.66), P < 0.01] were associated with increased odds of complications. A sub-analysis separating early versus late cases (after 2006) revealed a significantly increased frequency of surgical or endoscopic intervention (9.7 % vs 30.1% respectively, P = 0.04)
CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management. Although the frequency of surgical and endoscopic intervention has increased in recent years, outcomes have remained the same. Therefore, further research work is needed to better understand how to best treat this potentially lethal disease.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Nikoletta A Theochari
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Stamatina Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Konstantinos P Economopoulos
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Department of Surgery, Duke University Medical Center, Durham, NC 27708, United States
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
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Dias E, Santos-Antunes J, Macedo G. Diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2019; 32:529-540. [PMID: 31700229 PMCID: PMC6826069 DOI: 10.20524/aog.2019.0418] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.
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Affiliation(s)
- Emanuel Dias
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
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Abstract
Acute esophageal necrosis, commonly known as black esophagus, is a serious clinical condition that requires prompt diagnosis and management to improve morbidity and mortality. We present a 47-year-old woman who had this potentially lethal condition. The patient initially presented with hematemesis, and esophagogastroduodenoscopy at presentation showed diffuse esophageal ulcerations, erosions, and necrosis. During her admission, she required multiple blood transfusions for active bleeding, after which her clinical condition stabilized. Repeat esophagogastroduodenoscopy showed near-complete resolution of the earlier findings.
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Affiliation(s)
- Ibrahim Haddad
- Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, USA
| | - Mohammad Alomari
- Internal Medicine, Cleveland Clinic Foundation, Johnson City, USA
| | - Bara El Kurdi
- Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, USA
| | - Laith Al Momani
- Gastroenterology, University of Missouri Kansas City (UMKC), Kansas City, USA
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Abdullah HM, Ullah W, Abdallah M, Khan U, Hurairah A, Atiq M. Clinical presentations, management, and outcomes of acute esophageal necrosis: a systemic review. Expert Rev Gastroenterol Hepatol 2019; 13:507-514. [PMID: 30933549 DOI: 10.1080/17474124.2019.1601555] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND To review all the reported literature on acute esophageal necrosis. RESEARCH METHODS Databases were searched using the special Medical Subject Heading (MeSH) terms. All the available reported cases of acute esophageal necrosis were analyzed. RESULTS A total of 154 cases were identified and 130 cases were analyzed. The mean age of presentation was 61 years, and 70% of cases were males. The most common presenting symptoms were hematemesis in 66%, shock in 36%, melena in 33%, abdominal or substernal pain in 28%. The most common comorbidities reported were diabetes in 38%, hypertension in 37%, alcohol abuse in 25%, and chronic kidney disease in 16%. On upper endoscopy, 51% had a distal disease, 36% had pan esophageal, and only 2% had a proximal disease. 84% of patients were treated with IV Proton Pump Inhibitors, 22% received transfusions, 23% got antibiotics for underlying sepsis, 14% also received sucralfate, and 4% required surgery for treatment. The mortality rate was 32%, while perforation was reported in 5% and stricture formation reported in 9% of patients. CONCLUSIONS Patients with acute esophageal necrosis can have a favorable outcome if treated appropriately.
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Affiliation(s)
| | - Waqas Ullah
- b Abington Hospital - Jefferson Health , Abington , PA , USA
| | - Mohamed Abdallah
- a Sanford School of Medicine , University of South Dakota , Sioux Falls , SD , USA
| | - Uzma Khan
- c Khyber Teaching Hospital , Peshawar , Pakistan
| | | | - Muslim Atiq
- a Sanford School of Medicine , University of South Dakota , Sioux Falls , SD , USA
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Ullah W, Mehmood A, Micaily I, Khan MS. Comprehensive review of acute oesophageal necrosis. BMJ Case Rep 2019; 12:e227967. [PMID: 30814100 PMCID: PMC6398709 DOI: 10.1136/bcr-2018-227967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2019] [Indexed: 10/27/2022] Open
Abstract
Acute oesophageal necrosis, also known as 'black oesophagus', is a rare condition characterised by the black discolouration of the oesophageal mucosa on endoscopy and involves the distal oesophagus in majority of cases but may also extend proximally. A number of conditions are found to be associated with it and it is thought to occur due to a combination of hypovolaemia and inadequate oesophageal protective mucosal barrier function. Gastric secretions may have a direct effect on the oesophageal mucosa. We present a case of a woman who presented with haematemesis and significant hypotension after a session of haemodialysis. Black oesophagus was confirmed on esophagogastroduodenoscopy. She was given two units of packed red blood cells and one unit of platelets, and started on a pantoprazole infusion. However, despite rigorous attempts at resuscitation the patient failed to recover.
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Affiliation(s)
- Waqas Ullah
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Asif Mehmood
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Ida Micaily
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Muhammad Saeed Khan
- Department of Medicine, THQ Hospital Talash, Lower Dir, Khyber Pakhtunkhwa, Pakistan
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Sakatoku Y, Fukaya M, Miyata K, Nagino M. Successful bypass operation for esophageal obstruction after acute esophageal necrosis: a case report. Surg Case Rep 2017; 3:4. [PMID: 28054280 PMCID: PMC5215180 DOI: 10.1186/s40792-016-0277-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/14/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Acute esophageal necrosis (AEN) is a rare clinical disorder. Esophageal stenosis or obstruction is one of severe complications, but there are a few reports about surgical treatments. In such a situation, it still remains controversial which to choose, esophagectomy or bypass operation. CASE PRESENTATION A 61-year-old woman was admitted to the local hospital for septic shock with diabetic ketoacidosis due to necrotizing fasciitis of the right thigh. Three days later, she had hematemesis, and gastrointestinal endoscopy revealed black mucosal coloration throughout the entire esophagus. She was diagnosed as having AEN. Her general condition improved after intensive care, debridement, and treatment with antibiotics and a proton pump inhibitor; the esophageal mucosal color recovered. However, an esophageal stricture developed after 1 month, and the patient underwent gastrostomy to remove an esophageal obstruction after 3 months. She was referred to our hospital for surgical treatment 1 year and 4 months after the occurrence of AEN because of her strong desire for oral intake. Her medical condition was poor, and she could not walk due to generalized muscle weakness. After rehabilitation for 8 months, we performed an esophageal bypass using a gastric conduit via the percutaneous route rather than esophagectomy because of her multiple severe comorbidities including walking difficulty, chronic hepatitis C, cerebrovascular disease, and chronic renal failure. Minor leakage of the esophagogastrostomy occurred and was resolved with conservative treatment. The patient began oral intake on postoperative day 34 and was discharged on day 52. CONCLUSION Esophageal obstruction after AEN was successfully treated by esophageal bypass using a gastric conduit in a high-risk patient. Because the majority of patients with AEN have multiple severe comorbidities, assessing the medical condition of the patient adequately is important prior to choosing either an esophagectomy or bypass surgery.
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Affiliation(s)
- Yayoi Sakatoku
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Masahide Fukaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
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Abstract
Various domestic or industrial chemicals may cause significant upper aerodigestive tract burns. Preventive measures should be up-scaled, especially in the developing world, to reduce the epidemic of accidental victims, largely unsupervised preschool children. External signs do not predict degree of injury. Non-invasive diagnostic screening includes radio-nuclear imaging, but early oesophago-gastroduodenoscopy remains the standard to predict stricture formation from circumferential submucosal scarring. Serial dilation is the mainstay of oesophageal stricture therapy, with oesophageal replacement reserved for severe refractory strictures. Intra-lesional steroid or mitomycin C may decrease the dilatations required for severe strictures, although long-term effects are unknown. Risk of secondary oesophageal carcinoma mandates long-term surveillance.
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Affiliation(s)
- Marion Arnold
- Division of Paediatric Surgery, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Alp Numanoglu
- Division of Paediatric Surgery, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
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Yang K, Ling C, Yuan T, Zhu Y, Cheng Y, Cui W. Polymeric Biodegradable Stent Insertion in the Esophagus. Polymers (Basel) 2016; 8:E158. [PMID: 30979258 PMCID: PMC6432023 DOI: 10.3390/polym8050158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/03/2016] [Accepted: 04/08/2016] [Indexed: 12/11/2022] Open
Abstract
Esophageal stent insertion has been used as a well-accepted and effective alternative to manage and improve the quality of life for patients diagnosed with esophageal diseases and disorders. Current stents are either permanent or temporary and are fabricated from either metal or plastic. The partially covered self-expanding metal stent (SEMS) has a firm anchoring effect and prevent stent migration, however, the hyperplastic tissue reaction cause stent restenosis and make it difficult to remove. A fully covered SEMS and self-expanding plastic stent (SEPS) reduced reactive hyperplasia but has a high migration rate. The main advantage that polymeric biodegradable stents (BDSs) have over metal or plastic stents is that removal is not require and reduce the need for repeated stent insertion. But the slightly lower radial force of BDS may be its main shortcoming and a post-implant problem. Thus, strengthening support of BDS is a content of the research in the future. BDSs are often temporarily effective in esophageal stricture to relieve dysphagia. In the future, it can be expect that biodegradable drug-eluting stents (DES) will be available to treat benign esophageal stricture, perforations or leaks with additional use as palliative modalities for treating malignant esophageal stricture, as the bridge to surgery or to maintain luminal patency during neoadjuvant chemoradiation.
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Affiliation(s)
- Kai Yang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Christopher Ling
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
- Nanotechnology Engineering, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada.
| | - Tianwen Yuan
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Wenguo Cui
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
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