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Xue AZ, Anderson C, Cotton CC, Gaber CE, Feltner C, Dellon ES. Prevalence and Costs of Esophageal Strictures in the United States. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00308-2. [PMID: 38588766 DOI: 10.1016/j.cgh.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/13/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND & AIMS Esophageal strictures are a leading cause of dysphagia, but data regarding the epidemiology of esophageal strictures are limited. This study aimed to investigate the prevalence, health care utilization, and financial burden of esophageal strictures in the United States. METHODS We performed a retrospective cohort study using 2 large national insurance claims databases (MarketScan and Medicare). Using International Classification of Diseases-9 and -10 diagnostic codes, annual prevalence was calculated for both cohorts overall, and stratified by age and sex strata. Most common diagnostic and procedural codes associated with esophageal strictures were extracted and analyzed to estimate health care utilization. Direct annual medical costs of esophageal strictures were calculated. RESULTS The annual prevalence of esophageal strictures in MarketScan in 2021 was 203.14 cases/100,000 people, whereas the annual prevalence in Medicare cohort in 2017 was 1123.47 cases/100,000. Although rates were relatively stable over time, esophageal stricture prevalence increased with advancing age. No prevalence differences were noticed between males and females. Gastroesophageal reflux disease/erosive esophagitis was the top diagnostic code associated with esophageal strictures, although an increase in the proportion of eosinophilic esophagitis codes was noted over time. Esophageal dilation codes were present in ∼50% of stricture cases. The total health care costs associated with esophageal strictures were estimated at $1.39 billion in 2017. CONCLUSIONS Esophageal strictures are common, affecting between 1/100 and 1/1000 patients in the United States, with the highest rates seen in patients aged 75 years and older. Accordingly, strictures have a significant financial burden on the health care system, with costs greater than $1 billion annually.
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Affiliation(s)
- Angela Z Xue
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Chelsea Anderson
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Cary C Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Charles E Gaber
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois at Chicago, Chicago, Illinois
| | - Cynthia Feltner
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Pan Q, Tsuji Y, Sreedevi Madhavikutty A, Ohta S, Fujisawa A, Inagaki NF, Fujishiro M, Ito T. Prevention of esophageal stenosis via in situ cross-linkable alginate/gelatin powder in a new submucosal exfoliation model in rats. Biomater Sci 2023; 11:6781-6789. [PMID: 37614197 DOI: 10.1039/d3bm00887h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions often leads to postoperative stenosis, causing difficulty in swallowing, known as dysphagia. In this study, we developed an in situ cross-linkable powder composed of alginate, gelatin, transglutaminase (TG), and calcium chloride ions (Ca2+), which can be administered through a 1.5 m-long and 3.2 mm-diameter endoscopic instrument channel. The powdered mixture of alginate and gelatin quickly formed a hydrogel by absorbing body fluids and was cross-linked by TG and Ca2+, which adhered ex vivo to porcine submucosal layers for over 2 weeks. In addition, we developed a new submucosal exfoliation model in rats that induced severe stenosis, similar to the ESD-induced stenosis models in clinical practice. When administered to the new rat model, the powder system effectively reduced the severity of esophageal stenosis based on body weight change monitoring, anatomical findings, and histological analysis. The body weight of the rats was maintained at the initial weight on postoperative day 14 (POD14), and epithelialization on POD7 and 14 improved to almost 100%. Additionally, collagen accumulation and the number of α-SMA-positive cells decreased due to powder administration. Therefore, these findings indicate that the in situ cross-linkable powder can prevent esophageal stenosis after ESD.
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Affiliation(s)
- Qi Pan
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Yosuke Tsuji
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | | | - Seiichi Ohta
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Institute of Engineering Innovation, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Ayano Fujisawa
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Natsuko F Inagaki
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | - Taichi Ito
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Department of Chemical System Engineering, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
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3
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Sutanto H, Vidyani A. Complex Refractory Esophageal Stricture Due to Chronic Gasoline Ingestion: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1020. [PMID: 37374223 DOI: 10.3390/medicina59061020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Esophageal stricture is a narrowing of the esophageal lumen which is often characterized by impaired swallowing or dysphagia. It can be induced by inflammation, fibrosis or neoplasia which damages the mucosa and/or submucosa of the esophagus. Corrosive substance ingestion is one of the major causes of esophageal stricture, particularly in children and young adults. For instance, accidental ingestion or attempted suicide with corrosive household products is not uncommon. Gasoline is a liquid mixture of aliphatic hydrocarbons derived from the fractional distillation of petroleum, which is then combined with additives such as isooctane and aromatic hydrocarbons (e.g., toluene and benzene). Gasoline also contains several other additives including ethanol, methanol and formaldehyde, which make it a corrosive agent. Interestingly, to the best of our knowledge, the incidence of esophageal stricture caused by chronic gasoline ingestion has not been reported. In this paper, we report the case of a patient with dysphagia due to complex esophageal stricture due to chronic gasoline ingestion who underwent a series of esophago-gastro-duodenoscopy (EGD) procedures and repeated esophageal dilation.
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Affiliation(s)
- Henry Sutanto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
| | - Amie Vidyani
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
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Spaulding SL, Ansari E, Xing MH, Sandler ML, O'Malley QF, Ho R, Spitzer H, Levy J, Ganz C, Khorsandi AS, Mundi N, Urken ML. Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options. Am J Otolaryngol 2021; 42:103003. [PMID: 33894689 DOI: 10.1016/j.amjoto.2021.103003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES. METHODS The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps. RESULTS The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy. CONCLUSIONS The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.
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Affiliation(s)
- Sarah L Spaulding
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Edward Ansari
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Monica H Xing
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America.
| | - Mykayla L Sandler
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Quinn F O'Malley
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Rebecca Ho
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Hannah Spitzer
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Juliana Levy
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Cindy Ganz
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Azita S Khorsandi
- Department of Radiology, New York Eye and Ear Infirmary, New York, NY 10003, United States of America
| | - Neil Mundi
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Mark L Urken
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
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Gankov VA, Andreasyan AR, Maslikova SA, Bagdasaryan GI, Shestakov DY. THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-2-14-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.
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Pereira D, Sequeira I. A Scarless Healing Tale: Comparing Homeostasis and Wound Healing of Oral Mucosa With Skin and Oesophagus. Front Cell Dev Biol 2021; 9:682143. [PMID: 34381771 PMCID: PMC8350526 DOI: 10.3389/fcell.2021.682143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022] Open
Abstract
Epithelial tissues are the most rapidly dividing tissues in the body, holding a natural ability for renewal and regeneration. This ability is crucial for survival as epithelia are essential to provide the ultimate barrier against the external environment, protecting the underlying tissues. Tissue stem and progenitor cells are responsible for self-renewal and repair during homeostasis and following injury. Upon wounding, epithelial tissues undergo different phases of haemostasis, inflammation, proliferation and remodelling, often resulting in fibrosis and scarring. In this review, we explore the phenotypic differences between the skin, the oesophagus and the oral mucosa. We discuss the plasticity of these epithelial stem cells and contribution of different fibroblast subpopulations for tissue regeneration and wound healing. While these epithelial tissues share global mechanisms of stem cell behaviour for tissue renewal and regeneration, the oral mucosa is known for its outstanding healing potential with minimal scarring. We aim to provide an updated review of recent studies that combined cell therapy with bioengineering exporting the unique scarless properties of the oral mucosa to improve skin and oesophageal wound healing and to reduce fibrotic tissue formation. These advances open new avenues toward the ultimate goal of achieving scarless wound healing.
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Affiliation(s)
| | - Inês Sequeira
- Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Nakajo K, Yoda Y, Kadota T, Murano T, Shinmura K, Ikematsu H, Akimoto T, Yano T. Radial incision and cutting for dilation before endoscopic submucosal dissection in patients with esophageal cancer on the distal side of severe benign esophageal strictures. Dis Esophagus 2021; 34:5900452. [PMID: 32875339 DOI: 10.1093/dote/doaa092] [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: 06/01/2020] [Revised: 07/20/2020] [Accepted: 08/05/2020] [Indexed: 12/11/2022]
Abstract
We investigated the efficacy and safety of radial incision and cutting as a novel dilation method for strictures just before endoscopic submucosal dissection in patients with metachronous esophageal cancer localized on the distal side of strictures and determined the optimal dilation method. Consecutive patients who underwent endoscopic submucosal dissection for superficial esophageal squamous cell carcinomas localized on the distal side of severe strictures were investigated retrospectively and assigned to a radial incision and cutting (19 patients; 23 lesions) or an endoscopic balloon dilation (20 patients; 20 lesions) group. We evaluated the passage success rates of cap-wearing endoscopes with diameters ≥8.9 mm, the procedural success, en bloc resection, complete resection, major adverse event rates, and total procedure times. Compared to the endoscopic balloon dilation group, the passage success rate of a conventional endoscope with a transparent cap (87% vs. 50%) and procedural success rate (96% vs. 63%) were significantly higher in the radial incision and cutting group. The mean procedure time of 'dilation and ESD' was significantly shorter in the radial incision and cutting group than in the endoscopic balloon dilation group. Neither group experienced any serious adverse events. Radial incision and cutting followed by endoscopic submucosal dissection was effective and safe in patients with superficial esophageal squamous cell carcinomas localized on the distal side of severe benign esophageal strictures. Endoscopic submucosal dissection using a cap-wearing endoscope was possible with radial incision and cutting, and the procedure time was shorter than that for endoscopic balloon dilation.
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Affiliation(s)
- Keiichiro Nakajo
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan.,Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan
| | - Yusuke Yoda
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomohiro Kadota
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tatsuro Murano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kensuke Shinmura
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tetsuo Akimoto
- Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan.,Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
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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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Chae HK, Lee JH, Choi MC, Song WJ, Youn HY. Successful treatment of a dog with phenobarbital-responsive sialadenosis and an oesophageal stricture. Vet Med Sci 2021; 7:660-664. [PMID: 33410603 PMCID: PMC8136939 DOI: 10.1002/vms3.416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/28/2020] [Accepted: 12/09/2020] [Indexed: 01/24/2023] Open
Abstract
Background Phenobarbital‐responsive sialadenosis (PRS) can cause nausea and vomiting, and is rarely reported in dogs. Objectives An 8‐year‐old neutered, male Pomeranian dog was presented to our teaching hospital with vomiting that began 2 years ago. The clinical signs repeatedly improved and deteriorated despite treatment. Methods The only abnormality found on physical examination was salivary gland enlargement, and no specific findings were observed on blood analysis and imaging tests. The results of the fine needle aspirate cytology from the salivary glands revealed possible sialadenosis. Phenobarbital was prescribed, and the patient's symptoms resolved. However, upon discontinuing drug, the patient's clinical signs recurred and did not improve even after re‐introduction of phenobarbital and the addition of other anticonvulsant drugs. An oesophageal stricture was observed on an oesophagram, and fibrosis was confirmed endoscopically. A balloon dilation was performed to expand the stenosis. Results After the first procedure, the patient's clinical signs initially improved, but relapsed 2 weeks later. A total of three oesophageal dilation procedures were performed using a sequentially larger diameter balloon. After the third procedure, the patient's clinical signs were managed without recurrence. The cause of recurrent gastrointestinal signs following the initial successful treatment of phenobarbital‐responsive sialadenosis was due to oesophageal stricture formation. Conclusions This case report demonstrates the successful management of PRS with subsequent oesophageal stricture formation in a dog.
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Affiliation(s)
- Hyung-Kyu Chae
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jeong-Hwa Lee
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Min Cheol Choi
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Woo-Jin Song
- Department of Veterinary Internal Medicine and Research Institute of Veterinary Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Republic of Korea
| | - Hwa-Young Youn
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
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Utility of radial incision and cutting with steroid injection for refractory stricture after endoscopic submucosal dissection for large superficial esophageal squamous cell carcinoma. Surg Endosc 2021; 35:6930-6937. [PMID: 33398559 DOI: 10.1007/s00464-020-08204-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) for superficial esophagus squamous cell carcinoma (SESCC) may cause esophageal stricture and related dysphagia symptoms, especially when the lesion is widespread. Endoscopic balloon dilation (EBD) is the prior choice to treat post-ESD stricture. However, certain patients show poor response to EBD treatment and frequent dilations are required. We perform radial incision and cutting combined with intralesional steroid injection to manage refractory stricture. The study aims to evaluate the safety and efficacy of this new combined treatment. METHODS From October 2017 to February 2019, 25 patients who accepted repeated EBD because of refractory stricture after extensive ESD for large SESCC were enrolled. Radial incision and cutting followed by local steroid injection was performed on all the patients, and therapeutic EBD was conducted to treat recurring stricture after combined treatment. The incidence of recurrent stricture, clinical outcome of combined treatment, and following therapeutic EBD, procedure-related adverse events were assessed and analyzed. RESULTS During the follow-ups, the incidence of recurrent esophageal strictures was 92%. Combined treatment reduced the severity of stenosis and lowered the corresponding dysphagia scores significantly, compared with previous EBD. Mean symptom-relief duration of EBD was prolonged significantly from 29.9 to 76.0 days. Perforation was observed in one patient during operation and successfully sealed with metal clips. CONCLUSIONS Combination of radial incision and cutting with steroid injection is a safe and feasible treatment for esophageal refractory stricture after extensive ESD, appearing to improve the therapeutic EBD outcome and maintain a longer symptom-relief duration.
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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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12
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Lumen-apposing Metal Stents, Fully Covered Self-expanding Metal Stents, and Biodegradable Stents in the Management of Benign of GI Strictures: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019; 53:560-573. [PMID: 31149932 DOI: 10.1097/mcg.0000000000001228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Refractory benign gastrointestinal (GI) strictures are difficult to treat and placement of a stent is a commonly sought resort. Stents used for this purpose are fully covered self-expanding metal stent (FCSEMS), a biodegradable stent (BDS) and recently, a lumen-apposing metal stent (LAMS). There is no data comparing these stents to this end. METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2018) to identify studies that reported on the performance of FCSEMS, BDS, and LAMS in the treatment of refractory benign GI strictures. Our goals were to evaluate the pooled rate of technical success, clinical success, and adverse events with these stents and compare the outcomes between them. RESULTS A total of 31 studies were analyzed. In total, 14 (342 patients), 11 (226 patients), and 8 studies (192 patients) reported the use of FCSEMS, BDS, and LAMS, respectively. The pooled rate of technical success was 96.5% [95% confidence interval (CI): 93.5-98.1], 91.9% (95% CI: 85.6-95.6), and 97.6% (95% CI: 94.0-99.0) with FCSEMS, BDS, and LAMS respectively. No statistical significance to the difference was noted. The pooled rate of clinical success was 48.4% (95% CI: 37.1-59.8), 34.9% (95% CI: 23.6-48.1), and 78.8% (95% CI: 65.8-87.8) with FCSEMS, BDS, and LAMS, respectively. Statistical significance was noted in LAMS versus FCSEMS (P=0.001) and LAMS versus BDS (P=0.001). LAMS demonstrated statistically better outcomes in regards to stent migration and postprocedure pain when compared with FCSEMS and BDS. CONCLUSION Our study demonstrates that LAMS gives better clinical outcomes in the treatment of refractory benign GI strictures when compared with FCSEMS and BDS. Variability in the site, as well as the length of stricture, indirect comparison, and heterogeneity, were the limitations of our study.
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Sinha UK, Swanson MS, Villegas BC, Ouyoung LM, Kokot N. Outcomes of Self-Esophageal Dilation for Head and Neck Cancer Patients. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1060-1066. [PMID: 31112391 DOI: 10.1044/2019_ajslp-18-0190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Introduction Dysphagia is common following treatment for head and neck cancers, and self-esophageal dilation is a safe and effective treatment method. Prior studies on self-dilation have reported only qualitative results and included heterogeneous populations with dysphagia. The objective of this study is to quantitatively assess the safety and efficacy of a self-esophageal dilation program for patients with oropharyngeal squamous cell cancer with treatment-induced dysphagia. Materials and Methods This is a retrospective review of patients with oropharyngeal squamous cell cancer treated at the University of Southern California from 2009 to 2013 with dysphagia following radiation treatment that persisted after swallow therapy. The treatment program consisted of swallow therapy in conjunction with weekly self-esophageal dilation at home with increasing size bougie dilators. Oral intake was monitored using the Functional Oral Intake Scale (Crary, Mann, & Groher, 2005), Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score, and Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) pre- and posttreatment. Results Thirty-three patients met study criteria and completed the program. Twenty-five patients required nutrition via a gastrostomy tube prior to starting therapy, and 84% (21/25) of these patients were able to have the feeding tube removed. Median Functional Oral Intake Scale (Crary et al., 2005) predilation was 1 (range: 1-5), and postdilation was 6 (range: 3-6, p < .05). In addition, there was improvement of the Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score from 2 to 1 after treatment (p < .05). No complications were encountered. Discussion Home self-dilation with concurrent swallowing therapy is a safe and feasible procedure to be used in motivated patients with dysphagia following head and neck cancer treatment.
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Affiliation(s)
- Uttam K Sinha
- Department of Otolaryngology-Head and Neck Surgery, Keck School Medicine of the University of Southern California, Los Angeles
| | - Mark S Swanson
- Department of Otolaryngology-Head and Neck Surgery, Keck School Medicine of the University of Southern California, Los Angeles
| | - Brenda Capobres Villegas
- Department of Otolaryngology-Head and Neck Surgery, Keck School Medicine of the University of Southern California, Los Angeles
| | - Laishyang Melody Ouyoung
- Division of Speech Pathology, Keck Medical Center of the University of Southern California, Los Angeles
| | - Niels Kokot
- Department of Otolaryngology-Head and Neck Surgery, Keck School Medicine of the University of Southern California, Los Angeles
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Liu BR, Liu D, Yang W, Ullah S, Cao Z, He D, Zhang X, Shi Y, Zhou Y, Chen Y, He D, Zhao L, Yuan Y, Li D. Mucosal loss as a critical factor in esophageal stricture formation after mucosal resection: a pilot experiment in a porcine model. Surg Endosc 2019; 34:551-556. [PMID: 30980136 DOI: 10.1007/s00464-019-06793-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/09/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIM Esophageal stricture is a major complication of large areas endoscopic submucosal dissection (ESD). Until now, the critical mechanism of esophageal stricture remains unclear. We examined the role of mucosal loss versus submucosal damage in esophageal stricture formation after mucosal resection using a porcine model. MATERIALS AND METHODS Twelve swine were randomly divided into two groups, each of 6. In each group, two 5-cm-long submucosal tunnels were made to involve 1/3rd of the widths of the anterior and posterior esophageal circumference. The entire mucosal roofs of both tunnels were resected in group A. In group B, the tunnel roof mucosa was incised longitudinally along the length of the tunnel, but without excision of any mucosa. Stricture formation was evaluated by endoscopy after 1, 2, and 4 weeks, respectively. Anatomical and histological examinations were performed after euthanasia. RESULTS Healing observed on endoscopy in both groups after 1 week. Group A (mucosa resected) developed mild-to-severe esophageal stricture, dysphagia, and weight loss. In contrast, no esophageal stricture was evident in group B (mucosa incisions without resection) after 2 and 4 weeks, respectively. Macroscopic examination showed severe esophageal stricture and shortening of esophagus in only group A. Inflammation and fibrous hyperplasia of the submucosal layer was observed on histological examination in both groups. CONCLUSION The extent of loss of esophageal mucosa appears to be a critical factor for esophageal stricture. Inflammation followed by fibrosis may contribute to alteration in compliance of the esophagus but is not the main mechanism of postresection stricture.
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Affiliation(s)
- Bing-Rong Liu
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China.
| | - Dan Liu
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Wenyi Yang
- Department of Gastroenterology, First Affiliated Hospital of Henan University, Kaifeng, Henan, China
| | - Saif Ullah
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Zhen Cao
- Department of Gastroenterology, First Affiliated Hospital of Henan University, Kaifeng, Henan, China
| | - Dezhi He
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Xuehui Zhang
- Department of Gastroenterology, First Affiliated Hospital of Henan University, Kaifeng, Henan, China
| | - Yang Shi
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Yangyang Zhou
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Yong Chen
- Department of Gastroenterology, First Affiliated Hospital of Henan University, Kaifeng, Henan, China
| | - Donghai He
- Department of Gastroenterology, First Affiliated Hospital of Henan University, Kaifeng, Henan, China
| | - Lixia Zhao
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Yulian Yuan
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
| | - Deliang Li
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, China
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Kappelle WF, van Hooft JE, Spaander MCW, Vleggaar FP, Bruno MJ, Maluf-Filho F, Bogte A, van Halsema E, Siersema PD. Treatment of refractory post-esophagectomy anastomotic esophageal strictures using temporary fully covered esophageal metal stenting compared to repeated bougie dilation: results of a randomized controlled trial. Endosc Int Open 2019; 7:E178-E185. [PMID: 30705950 PMCID: PMC6338544 DOI: 10.1055/a-0777-1856] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/24/2018] [Indexed: 12/31/2022] Open
Abstract
Background and study aims Fully covered self-expanding metal stents (FCSEMS) provide an alternative to bougie dilation (BD) for refractory benign esophageal strictures. Controlled studies comparing temporary placement of FCSES to repeated BD are not available. Patients and methods Patients with refractory anastomotic esophageal strictures, dysphagia scores ≥ 2, and two to five prior BD were randomized to 8 weeks of FCSEMS or to repeated BD. The primary endpoint was the number of BD during the 12 months after baseline treatment. Results Eighteen patients were included (male 67 %, median age 66.5; 9 received metal stents, 9 received BD). Technical success rate of stent placement and stent removal was 100 %. Recurrent dysphagia occurred in 13 patients (72 %) during follow-up. No significant difference was found between the stent and BD groups for mean number of BD during follow-up (5.4 vs. 2.4, P = 0.159), time to recurrent dysphagia (median 36 days vs. 33 days, Kaplan-Meier: P = 0.576) and frequency of reinterventions per month (median 0.3 vs. 0.2, P = 0.283). Improvement in quality of life score was greater in the stent group compared to the BD group at month 12 (median 26 % vs. 4 %, P = 0.011). Conclusions The current data did not provide evidence for a statistically significant difference between the two groups in the number of BD during the 12 months after initial treatment. Metal stenting offers greater improvement in quality of life from baseline at 12 months compared to repeated BD for patients with refractory anastomotic esophageal strictures.
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Affiliation(s)
- W. F. Kappelle
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - F. P. Vleggaar
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. J. Bruno
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F. Maluf-Filho
- Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil
| | - A. Bogte
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - P. D. Siersema
- University Medical Center Utrecht, Utrecht, The Netherlands,Radboud University Medical Center, Nijmegen, The Netherlands,Corresponding author Peter D. Siersema, MD, PhD Dept. of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands+31 10 465 8520
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Hallac A, Srikureja W, Liu E, Dhumal P, Thatte A, Puri N. Economical effect of lumen apposing metal stents for treating benign foregut strictures. World J Gastrointest Endosc 2018; 10:294-300. [PMID: 30364856 PMCID: PMC6198308 DOI: 10.4253/wjge.v10.i10.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/27/2018] [Accepted: 08/21/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the clinical and economical efficacy of lumen apposing metal stent (LAMS) in the treatment of benign foregut strictures.
METHODS A single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and five-parameter regression analysis
RESULTS Nine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS (stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall. LAMS was cost effective after two dilations in the Post-surgical stricture subgroup.
CONCLUSION Endoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.
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Affiliation(s)
| | | | - Eashen Liu
- Providence Gastroenterology, Spokane, WA 99204, United States
| | - Parag Dhumal
- College of Business, Economics and Computing, University of Wisconsin-Parkside, Kenosha, WI 53144, United States
| | - Ashish Thatte
- School of Business Administration, Gonzaga University, Spokane, WA 99258, United States
| | - Nishant Puri
- Providence Gastroenterology, Spokane, WA 99204, United States
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Endoscopic Balloon Dilation Followed By Intralesional Steroid Injection for Anastomotic Strictures After Esophagectomy: A Randomized Controlled Trial. Am J Gastroenterol 2018; 113:1468-1474. [PMID: 30181533 DOI: 10.1038/s41395-018-0253-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic balloon dilation (EBD) is a standard treatment for anastomotic strictures after esophagectomy, and requires multiple dilations. We conducted a randomized controlled trial to assess the efficacy of adding a steroid injection to EBD to reduce restricture. METHODS Patients were randomized to receive EBD combined with either triamcinolone or placebo injection. The primary endpoint was the number of dilations required to resolve the stricture. The secondary endpoints were restricture-free survival and adverse events. Patients with a dysphagia symptom score of ≥2 after esophagectomy with an endoscopy-confirmed anastomotic stricture were included. A total of 50 mg of triamcinolone acetonide (50 mg/5 mL) or an identical volume of normal saline solution as a placebo was injected per site using a 25-gauge needle immediately after EBD. Both the patient and treating physician were blinded to the treatment given. RESULTS During the 4-year study period, 65 patients were randomized to either the steroid group (n = 33) or placebo group (n = 32). The median number of EBDs required to resolve strictures was 2.0 (interquartile range, 1.0-2.5) in the steroid group and 4.0 (interquartile range, 2.0-6.8) in the placebo group (p < 0.001). After 6 months of follow-up, 39% of patients who had received steroid injections remained recurrence free compared with 16% of those who had received saline injections (p = 0.002). No adverse events occurred during follow-up. CONCLUSIONS Steroid injection shows promising results for the prevention of stricture recurrence in patients who underwent EBD for anastomotic strictures.
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Efficacy and Safety of Endoscopic Intralesional Triamcinolone Injection for Benign Esophageal Strictures. Gastroenterol Res Pract 2018; 2018:7619298. [PMID: 30158968 PMCID: PMC6109539 DOI: 10.1155/2018/7619298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/05/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022] Open
Abstract
Objectives To evaluate the efficacy and safety of endoscopic intralesional triamcinolone injection (ITI) for benign esophageal strictures combined with endoscopic dilation (ED). Methods Online databases including MEDLINE, EMBASE, the Cochrane Library, and Web of Science were comprehensively searched for prospective randomized control trials (RCTs) between 1966 and March 2018. A meta-analysis was conducted according to the methods recommended by the Cochrane Collaboration. Results Six RCTs consisting of 176 patients were selected. Meta-analysis results showed that additional ITI had a significant advantage in terms of stricture rate and required ED sessions. Surgery-related and non-surgery-related strictures showed similar results. Additional ITI was not associated with significantly increased risk of complications. Conclusions Our meta-analysis showed that additional ITI therapy was supposed to be effective and safe for benign esophageal strictures as it reduced the stricture rate and required ED sessions. However, more RCTs are necessary to support these findings.
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Surgery in Benign Oesophageal Disease. Dysphagia 2018. [DOI: 10.1007/174_2018_178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zhu YQ, Yang K, Edmonds L, Wei LM, Zheng R, Cheng RY, Cui WG, Cheng YS. Silicone-covered biodegradable magnesium-stent insertion in the esophagus: a comparison with plastic stents. Therap Adv Gastroenterol 2017; 10:11-19. [PMID: 28286555 PMCID: PMC5330610 DOI: 10.1177/1756283x16671670] [Citation(s) in RCA: 7] [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] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We determined the feasibility of, and tissue response to silicone-covered biodegradable magnesium- and plastic-stent insertion into the esophagus in rabbits. METHODS The mechanical compression-recovery characteristics and degradation behaviors of the magnesium stent were investigated in vitro. A total of 45 rabbits were randomly divided into a magnesium- (n = 15) and a plastic- (n = 15) stent group, and underwent stent insertion into the lower third of the esophagus under fluoroscopic guidance; a control group (n = 15) did not undergo the intervention. Esophagography was performed at 1, 2, and 4 weeks. Five rabbits in each group were euthanized at each time point for histological examination. RESULTS Silicone-covered magnesium stents showed similar radial force to plastic stents (p > 0.05). The magnesium stents degraded rapidly in an acidic solution, but 90.2% ± 3.1% of the residual mass was maintained after a 2-week degradation in a solution with a pH of 4.0. All stent insertions were well tolerated. Magnesium stents migrated in six rabbits (one at 1 week, one at 2 weeks and four at 4 weeks), and plastic stents migrated in three rabbits (one at 2 weeks and two at 4 weeks; p > 0.05). Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was similar in both stented groups (p > 0.05), and the esophagus wall was found to be significantly thinner in the stented groups than in the control group (p < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ from the control group (p > 0.05). CONCLUSIONS Esophageal silicone-covered magnesium stents provided reliable support for at least 2 weeks, with acceptable migration rates and without causing severe injury or tissue reaction compared with plastic stents.
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Affiliation(s)
- Yue-Qi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, China
| | - Kai Yang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, China
| | - Laura Edmonds
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, China and Nanotechnology Engineering, University of Waterloo, Ontario, Canada
| | - Li-Ming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, China
| | - Reila Zheng
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, China
| | - Ruo-Yu Cheng
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, China
| | - Wen-Guo Cui
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yi Shan Road, Shanghai, 200233, China and Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, No. 708 Renmin Rd, Suzhou, Jiangsu 215006, China
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Zhu YQ, Edmonds L, Wei LM, Zheng RL, Cheng RY, Cui WG, Cheng YS. Technical feasibility and tissue reaction after silicone-covered biodegradable magnesium stent insertion in the oesophagus: a primary study in vitro and in vivo. Eur Radiol 2016; 27:2546-2553. [PMID: 27704201 DOI: 10.1007/s00330-016-4602-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/08/2016] [Accepted: 09/07/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Determine the feasibility of and tissue response to biodegradable magnesium-silicone stent insertion into the oesophagus of rabbits. METHODS Mechanical compression-recovery and degradation behaviours of the stents were investigated in vitro. Thirty rabbits were randomly divided into a magnesium-silicone stent group (n = 15) that received stent insertion into the lower 1/3 of the oesophagus under fluoroscopic guidance and a control group (n = 15). Oesophagography was performed at 1, 2 and 4 weeks. Five rabbits in each group were euthanized at each time point for histological examination. RESULTS Magnesium-silicone stents showed good flexibility and elasticity, and degraded more slowly than bare stents at pH 4.0 and 7.4. All stent insertions were well tolerated. The oesophageal diameters at 1, 2 and 4 weeks were 9.7 ± 0.7, 9.6 ± 0.8 and 9.6 ± 0.5 mm, respectively (vs. 9.2 ± 0.8 mm before intervention; P > 0.05). Stent migration occurred in six rabbits (one at 1 week, one at 2 and four at 4). Microscopy demonstrated dilation of the oesophageal wall within 1 week of insertion. Oesophageal injury and collagen deposition following stent insertion were similar to control (P > 0.05). CONCLUSIONS Oesophageal magnesium-silicone stent insertion was feasible and provided reliable support for 2 weeks without causing oesophageal injury or collagen deposition. KEY POINTS • Mg stent provided apparently adequate radial force and silicone membrane reduced magnesium biodegradation • Stent insertion provided good support for at least 2 weeks before biodegradation • Stenting effectively resulted in oesophageal wall remodelling, without demonstrable injury.
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Affiliation(s)
- Yue-Qi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yi Shan Road, Shanghai, 200233, China
| | - Laura Edmonds
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Rd, Suzhou, Jiangsu, 215006, People's Republic of China.,Nanotechnology Engineering, University of Waterloo, Waterloo, Ontario, N2L3G1, Canada
| | - Li-Ming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yi Shan Road, Shanghai, 200233, China
| | - Rei-La Zheng
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Rd, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Ruo-Yu Cheng
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Rd, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Wen-Guo Cui
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Rd, Suzhou, Jiangsu, 215006, People's Republic of China.
| | - Ying-Sheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yi Shan Road, Shanghai, 200233, China.
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Fukaya M, Abe T, Nagino M. Rapid progressive long esophageal stricture caused by gastroesophageal reflux disease after pylorus-preserving pancreatoduodenectomy. BMC Surg 2016; 16:19. [PMID: 27090811 PMCID: PMC4836191 DOI: 10.1186/s12893-016-0137-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/08/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a major postoperative complication after pylorus-preserving pancreatoduodenectomy (PpPD) and sometimes causes reflux esophagitis. In most cases, this morbidity is controllable by proton-pump inhibitor (PPI) and very rarely results in esophageal stricture. Balloon dilation is usually performed for benign esophageal stricture, and esophagectomy was rarely elected. In the present case, there were two important problems of surgical procedure; how to perform esophageal reconstruction after PpPD and whether to preserve the stomach or not. CASE PRESENTATION A 63-year-old man underwent PpPD and Child reconstruction with Braun anastomosis for lower bile duct carcinoma. Two weeks after surgery DGE occurred, and a 10 cm long stricture from middle esophagus to cardia developed one and a half month after surgery in spite of the administration of antacids. Balloon dilation was performed, but perforation occurred. It was recovered with conservative treatment. Even the administration of a proton pump inhibitor (PPI) for approximately five mouths did not improve esophageal stricture. Simultaneous 24-h pH and bilirubin monitoring confirmed that this patient was resistant to PPI. We performed middle-lower esophagectomy with total gastrectomy to prevent gastric acid from injuring reconstructed organ and remnant esophagus through a right thoracoabdominal incision, and we also performed reconstruction with transverse colon, adding Roux-Y anastomosis, to prevent bile reflux to the remnant esophagus. Minor leakage developed during the postoperative course but was soon cured by conservative treatment. The patient started oral intake on the 25th postoperative day (POD) and was discharged on the 34th POD in good condition. CONCLUSION Long esophageal stricture after PpPD was successfully treated by middle-lower esophagectomy and total gastrectomy with transverse colon reconstruction through a right thoracoabdominal incision. Conventional PD or SSPPD with Roux-en Y reconstruction rather than PpPD should be selected to reduce the risk of DGE and prevent bile reflux, in performing PD for patients with hiatal hernia or rapid metabolizer CYP2C19 genotype; otherwise, fundoplication such as Nissen and Toupet should be added.
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Affiliation(s)
- Masahide Fukaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, 466-8550, Japan.
| | - Tetsuya Abe
- 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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Khokhar HA, Azeem B, Bughio M, Bass GA, Elfadul A, Salih M, Fahmy W, Walsh TN. Trans-Balloon Visualisation During Dilatation (TBVD) of Oesophageal Strictures: a Novel Innovation. J Gastrointest Surg 2016; 20:674-9. [PMID: 26585885 DOI: 10.1007/s11605-015-3024-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/09/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hydrostatic balloon dilatation of upper gastrointestinal strictures is associated with a risk of perforation that varies with the underlying pathology and with the technique employed. We present a technique of trans-balloon visualisation of the stricture during dilatation (TBVD) that allows direct 'real-time' observation of the effect of dilatation on the stricture, facilitating early recognition of mucosal abruption, thereby reducing the perforation rate. PATIENTS AND METHODS We retrospectively analysed 100 consecutive patients, undergoing balloon dilatation of oesophageal strictures between 1st of January 2011 and 1st of July 2014. RESULTS One hundred patients underwent 186 dilatations, with 34 having multiple procedures (mean 1.86). All had oesophageal strictures (mean diameter 8.49 mm, range 5-11 mm) and most underwent dilatation up to a maximum of 17 mm (mean 14.7 mm). Fifty-six percent were male and the average age was 62.5 years (17-89 years). Only one patient (0.5% of all procedures) had a full-thickness perforation requiring intervention while just one further patient had a deep mucosal tear that did not require intervention. CONCLUSIONS TBVD is a safe technique with a short learning curve and is one of the important factors that allow potentially difficult dilatations to be performed safely with an exceptionally low rate of adverse events of less than 1%.
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Affiliation(s)
- Haseeb A Khokhar
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland.
- , 9 The Avenue, Highfield Park, Ballincollig, County Cork, Ireland.
| | - Beenish Azeem
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Mumtaz Bughio
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Gary A Bass
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Amr Elfadul
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Monim Salih
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Waleed Fahmy
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
| | - Thomas N Walsh
- Upper GI Surgical Department, Connolly Hospital Blanchardstown, Dublin 15, Ireland
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Abstract
BACKGROUND AND AIMS Refractory benign gastrointestinal (GI) strictures represent a difficult management problem given the limited therapeutic interventions available. We performed a systematic review of all published cases using mitomycin C in the treatment of GI strictures. METHODS Searches of MEDLINE and Embase databases were performed to identify studies reporting application of mitomycin C for GI strictures. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction were performed independently by 2 authors. RESULTS Of 549 citations, 24 studies with 145 patients (74% pediatric and 26% adult) met inclusion criteria. Esophageal strictures were the most common (79%) site of refractory strictures treated with mitomycin C, with caustic injury the most common underlying etiology. The concentration (range, 0.1 to 2 mg/mL; median, 0.4 mg/mL), number of applications (range, 1 to 12; median, 1), duration of applications (range, 1 to 5; median, 2 min), and technique of application (cotton pledget, spray, injection, special catheters) varied among studies. Ninety-one patients (73%; children: 80%, adults: 59%) had a complete response; 26 (21%) had a partial response. Only 1 (0.7%) adverse event was reported: cutaneous sclerosis attributed to microperforation and mitomycin C extravastion after injection. Mean follow-up was 23 (4 to 60) months. CONCLUSIONS Local mitomycin C application seems to be a safe and effective therapy for benign refractory GI strictures of varying etiology in both pediatric and adult populations. Although the results of this systematic review are highly encouraging, it should be considered investigational. Additional randomized trials and larger prospective studies are needed to confirm these results and to better define the optimal dose, concentration, duration and technique of mitomycin C application.
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PEPTIC STRICTURE MIMICKING ESOPHAGEAL CANCER: A CASE REPORT. Gastroenterol Nurs 2015; 38:384-6. [PMID: 26422273 DOI: 10.1097/sga.0000000000000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Vasilevskiy DI, Skurihin SS, Luft AV, Mednikov SN, Silantiev DS, Kulagin VI, Dvoretskiy SY, Bagnenko SF. [Prevalence of erosive esophagitis and peptic esophageal strictures]. Khirurgiia (Mosk) 2015:35-37. [PMID: 26271421 DOI: 10.17116/hirurgia2015635-37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gastroesophageal reflux disease is a widespread among population in economically developed countries including Russia. It was analyzed the results of 34 903 endoscopic examinations of upper gastrointestinal tract in ethnically and socially homogeneous population of Leningrad region with symptoms of gastric dispepsia. Procedures were performed for the period 2007-2013. Prevalence of erosive esophagitis was 4.9%. Peptic esophageal strictures due to chronic reflux-associated inflammation were revealed in 0.2% of examined patients (3.7% of patients with erosive esophagitis). Obtained data allow to considergastroesophageal reflux disease as a socially significant problem in Russia requiring close attention and further study.
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Affiliation(s)
- D I Vasilevskiy
- Leningrad Regional Clinical Hospital, St. Petersburg, Russia
| | - S S Skurihin
- Leningrad Regional Clinical Hospital, St. Petersburg, Russia
| | - A V Luft
- Leningrad Regional Clinical Hospital, St. Petersburg, Russia
| | - S N Mednikov
- Leningrad Regional Office for autopsy, St. Petersburg, Russia
| | - D S Silantiev
- Leningrad Regional Clinical Hospital, St. Petersburg, Russia
| | - V I Kulagin
- Janelidze Research Institute of Emergency medicine, St. Petersburg, Russia
| | - S Yu Dvoretskiy
- Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
| | - S F Bagnenko
- Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
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Liu J, Shang L, Liu JY, Qin CY. Newly designed “pieced” stent in a rabbit model of benign esophageal stricture. World J Gastroenterol 2015; 21:8629-8635. [PMID: 26229404 PMCID: PMC4515843 DOI: 10.3748/wjg.v21.i28.8629] [Citation(s) in RCA: 5] [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: 02/05/2015] [Revised: 03/26/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate a newly designed stent and its dilatation effect in a rabbit model of benign esophageal stricture.
METHODS: Thirty-four New Zealand white rabbits underwent a corrosive injury in the middle esophagus for esophageal stricture formation. Thirty rabbits with a successful formation of esophageal strictures were randomly allocated into two groups. The control group (n = 15) was implanted with a conventional stent, and the study group (n = 15) was implanted with a detachable “pieced” stent. The study stent (30 mm in length, 10 mm in diameter) was composed of three covered metallic pieces connected by surgical suture lines. The stent was collapsed by pulling the suture lines out of the mesh. Two weeks after stricture formation, endoscopic placement of a conventional stent or the new stent was performed. Endoscopic extraction was carried out four weeks later. The extraction rate, ease of extraction, migration, complications, and survival were evaluated.
RESULTS: Stent migration occurred in 3/15 (20%) animals in the control group and 2/15 (13%) animals in the study group; the difference between the two groups was not statistically significant. At the end of four weeks, the remaining stents were successfully extracted with the endoscope in 100% (11/11) of the animals in the study group, and 60% (6/10) of the animals in the control group; this difference was statistically significant (P < 0.05). There was no difference in the mean number of follow-up days between the control and study groups (25.33 vs 25.85). Minor bleeding was reported in five cases in the study group and four in the control group. There were no severe complications directly associated with stent implantation or extraction in either of the two groups.
CONCLUSION: In this experimental protocol of benign esophageal strictures, the novel “pieced” stent demonstrated a superior removal rate with a similar migration rate compared to a conventional stent.
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Endoscopic incision with esophageal stent placement for the treatment of refractory benign esophageal strictures. Gastrointest Endosc 2015; 81:1036-40. [PMID: 25805475 DOI: 10.1016/j.gie.2014.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022]
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Liu D, Tan Y, Zhang J, Huo J. Endoscopic incision with esophageal stenting helped to remove a gastrostomy tube in a patient with refractory stricture. Intern Med 2015; 54:473-5. [PMID: 25758072 DOI: 10.2169/internalmedicine.54.3360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Most cases of esophageal benign stricture can be successfully managed with dilation; however, refractory stricture is often unresponsive to repeated dilation. Endoscopic incision is a novel technique for treating refractory esophageal stricture, although recurrence is noted in patients with stricture measuring greater than 1.5 cm, thus requiring the use of repeated incisions and/or preventive dilation. We herein report a case of refractory esophageal stricture treated with an endoscopic incision and esophageal stenting, which successfully allowed the gastrostomy tube to be removed.
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Affiliation(s)
- Deliang Liu
- Department of Gastroenterology, The Second XiangYa Hospital of Central South University, China
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Zhu Y, Edmonds L, Zhao X, Chen X, Hu C, Cheng Y, Cui W. In vitro and in vivo evaluation of Rapamycin-eluting nanofibers coated on cardia stents. RSC Adv 2014. [DOI: 10.1039/c4ra04771k] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Diagram of the process used to fabricate non-biodegradable metal stents with an outer layer of Rapa-loaded fibrous membrane using the electrospinning process. With the release of Rapa, the stents are expected to inhibit fibroblast proliferation and tissue hyperplasia, therefore treating a benign cardia stricture.
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Affiliation(s)
- Yueqi Zhu
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
- Department of Radiology
- The Sixth Affiliated People's Hospital
| | - Laura Edmonds
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Xin Zhao
- Center for Biomedical Engineering
- Department of Medicine
- Brigham and Women's Hospital
- Harvard Medical School
- Cambridge, USA
| | - Xinliang Chen
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Changmin Hu
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Yingsheng Cheng
- Department of Radiology
- The Sixth Affiliated People's Hospital
- Medical School of Shanghai Jiao Tong University
- Shanghai, P.R. China
| | - Wenguo Cui
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
- Department of Orthopedics
- The First Affiliated Hospital of Soochow University
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31
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Hwang JC, Jin B, Kim JH, Lim SG, Yang MJ, Kim SS, Shin SJ, Lee KM, Kim JH. Esophageal stricture induced by an ultraslim upper endoscope in a novel rabbit model of corrosive injury. Scand J Gastroenterol 2014; 49:30-4. [PMID: 24164403 DOI: 10.3109/00365521.2013.848229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Benign esophageal strictures are regularly encountered problems in clinical practice. The management of refractory benign esophageal stricture, which fails to establish adequate food passage despite multiple dilatation sessions, has been considered challenging. Experimental animal models are essential for the development of effective treatment methods. The aim of this study was to establish a new animal model of benign esophageal stricture using rabbits. MATERIAL AND METHODS Corrosive injury of the esophagus was induced by administration of 1 ml of 1.5% sodium hydroxide in eight rabbits using an ultraslim upper endoscope equipped with a 5-Fr polytetrafluoroethylene tube and 5-Fr balloon catheter. Two weeks after corrosive injury, endoscopic examination was performed to confirm the state of the injury site. Four weeks after corrosive injury, the esophageal stricture was assessed by endoscopy and esophagography. All animals were then euthanized. RESULTS Two weeks after corrosive injury, endoscopic examination showed that ulceration had been induced. Four weeks after corrosive injury, endoscopic, radiologic and gross examinations showed that esophageal stricture had been induced without complications in all animals. The esophageal lumen diameter was reduced by an average of 51.8% (range, 48.3%-57.2%), and the mean stricture length was 25.7 mm (range, 20.1-29.3 mm). Microscopic examination revealed focal ulceration and submucosal thickening secondary to fibrosis. CONCLUSIONS Rabbit esophageal stricture induced by endoscopic delivery of a small amount of low-concentration sodium hydroxide is a relatively simple, safe, and reproducible animal model. This model may be useful in the development of new treatment methods for esophageal stricture.
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Affiliation(s)
- Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine , Suwon , Korea
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Zhang C, Zhou X, Yu L, Ding J, Shi R. Endoscopic therapy in the treatment of caustic esophageal stricture: a retrospective case series study. Dig Endosc 2013; 25:490-5. [PMID: 23369028 DOI: 10.1111/den.12023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 11/20/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic procedures, such as balloon/bougie dilation and stent implantation, have gained increasing potential as the treatment of corrosive esophageal stricture. The purpose of the present retrospective case series study was to assess clinical outcomes of endoscopic therapy of esophageal strictures after caustic injury. PATIENTS AND METHODS Between January 2003 and December 2009, 13 admitted patients that developed esophageal stricture after caustic agent ingestion underwent endoscopic therapy at the First Affiliated Hospital of Nanjing Medical University. Data such as age, gender, caustic agents, site of burn, type of treatment, effectiveness and outcome of endoscopic therapy were recorded. RESULTS The average follow up was 39 months with a range of 29-70 months. Successful endoscopic therapy was achieved in 12 of 13 patients (92%). Duration of stricture resolution was between 4 and 48 months (mean, 15 months). Among them, seven patients required dilations only, whereas the other five patients received both dilations and stent implantation. There were no severe complications in these patients. CONCLUSIONS These data suggest that endoscopic therapy is feasible, less invasive and effective for the management of caustic esophageal stricture. After repeat dilation and stenting, patients can achieve stricture resolution in approximately 15 months and avoid surgery.
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Affiliation(s)
- Cuiling Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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33
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Sato H, Inoue H, Kobayashi Y, Maselli R, Santi EGR, Hayee B, Igarashi K, Yoshida A, Ikeda H, Onimaru M, Aoyagi Y, Kudo SE. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78:250-7. [PMID: 23453294 DOI: 10.1016/j.gie.2013.01.008] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 01/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD). OBJECTIVE To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus). INTERVENTION After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks. MAIN OUTCOME MEASUREMENTS Total number of EBD sessions and total EBD period (months). RESULTS Steroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group. LIMITATIONS Nonrandomized study; retrospective analysis. CONCLUSION After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD.
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Affiliation(s)
- Hiroki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
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Parolini F, Leva E, Morandi A, Macchini F, Gentilino V, Di Cesare A, Torricelli M. Anastomotic strictures and endoscopic dilatations following esophageal atresia repair. Pediatr Surg Int 2013; 29:601-5. [PMID: 23519549 DOI: 10.1007/s00383-013-3298-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify risk factors that can predict prevalence of anastomotic strictures (AS) following esophageal atresia (EA) repair. METHODS Of 46 consecutive patients with EA managed at our institution between 2004 and 2012, 35 underwent esophageal anastomosis and were included in this retrospective longitudinal study. Routine endoscopy was performed 1 month after surgical repair. According to stricture index (SI), endoscopically calculated as SI = (D - d)/D, where D is the diameter of the esophageal pouch and d the stricture diameter, population was divided into Group 1, SI ≤ 0.1 (no evidence of stricture); Group 2, 0.3 > SI > 0.1 (mild stricture); Group 3, SI ≥ 0.3 (high-grade stricture). Trends of subsequent endoscopic esophageal dilatations were compared between the groups using Wilcoxon-Mann-Whitney or Pearson's tests. Cox regression analysis was performed to estimate the hazard ratio. RESULTS Gastro-esophageal reflux disease (P = 0.04), tension on the anastomosis (P = 0.02) and long-gap form (P = 0.008) have an increased risk of developing AS. SI at 1 month after surgery correlates with the average number of future dilatations: Group 2 and 3 compared to Group 1 required more dilatations (hazard ratio 2.291 and 12.765). CONCLUSION AS remain frequent complications of esophageal surgery, especially in specific subgroups of patients. SI at 1 month after surgery could already predict the severity of the stricture and the need for subsequent endoscopic esophageal dilatations.
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Affiliation(s)
- Filippo Parolini
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Padiglione Alfieri (Chirurgia Pediatrica), Via Commenda, 10, 20122 Milan, Italy.
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Wallner O, Wallner B. Balloon dilation of benign esophageal rings or strictures: a randomized clinical trial comparing two different inflation times. Dis Esophagus 2013; 27:109-11. [PMID: 23621385 DOI: 10.1111/dote.12080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although balloon dilatation is the primary treatment for benign dysphagia, information about the optimal inflation time is lacking. The aim of the current pilot study was to compare 10 seconds inflation time with 2 minutes inflation time, regarding the efficacy. Twenty patients with symptomatic strictures were prospectively studied in a randomized fashion. The 10-second group required an average of 1.4 dilations per patient; the 2-minute group required an average of 1.5 dilations per patient. This pilot study indicates that 10 seconds inflation time is as effective as 2 minutes. Because the treatment is both painful and unpleasant, this is an important finding.
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Affiliation(s)
- O Wallner
- Department of Surgical Sciences, Section of Surgery, Uppsala University Hospital, Uppsala
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36
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Gallo A, Pagliuca G, de Vincentiis M, Martellucci S, Iallonardi E, Fanello G, Cereatti F, Fiocca F. Endoscopic Treatment of Benign and Malignant Strictures of the Cervical Esophagus and Hypopharynx. Ann Otol Rhinol Laryngol 2012; 121:104-9. [DOI: 10.1177/000348941212100206] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We evaluated the efficacy of endoscopic techniques employed in the management of cervical esophageal and hypopharyngeal strictures. Methods: A series of 45 patients with cervical esophageal (35) and/or hypopharyngeal strictures (10) were included. Twenty-five patients (55.6%) with neoplastic strictures were treated for palliation alone. The stenosis was related to radiotherapy in 11 patients (24.4%) and to postsurgical complications in 9 (20%). A group of 23 patients was treated with dilation alone (group 1). A second group included 22 patients treated with insertion of a self-expandable stent after failure of dilation treatment (group 2). The swallowing test data, clinical notes, and surgical reports were reviewed. Results: All of the patients showed some degree of relief of dysphagia. In group 1, 19 of the 23 patients required multiple dilation treatments to maintain normal deglutition. In group 2, 7 of the 22 patients recovered regular oral feeding after stent placement, 10 patients reported pain and foreign body sensation, 2 patients reported pain so severe that stent removal was required, and 3 patients experienced stent migration. All but 3 of the 25 patients with inoperable tumors died during follow-up, but no patients with benign stenosis died. Conclusions: The two groups showed comparable functional results. Dilation often requires multiple procedures, but is usually well tolerated. Placement of self-expandable stents is effective, but is generally less well tolerated.
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Conway JD, Ott DJ, Chen MY. Intervention on the Esophagus. Dysphagia 2012. [DOI: 10.1007/174_2012_607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.
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Motoyama S, Saito R, Morii M, Yoshino H, Hebiguchi T, Ogawa JI. Transhiatal jejunal interposition preserving the whole stomach and vagal trunk for a benign esophageal stricture in a male adolescent: report of a case. Surg Today 2011; 41:1567-70. [PMID: 21969164 DOI: 10.1007/s00595-010-4539-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 11/08/2010] [Indexed: 12/30/2022]
Abstract
Benign esophageal strictures are generally treated with medication and balloon dilation; however, when repeated dilations fail, surgery is the only option. When performing surgery for benign esophageal stricture in young patients, it is important to consider not only the surgical stress and likelihood of complications but also digestive function after reconstruction, the durability of the reconstruction, and the potential for cancerous change in the reconstructed organs. We describe how we treated a 14-year-old boy with benign esophageal stricture by performing transhiatal esophagectomy assisted by mediastinoscopy, preserving the whole stomach and vagus nerve, and interposing pedicled jejunum between the cervical esophagus and stomach through a posterior mediastinal route, with good long-term results.
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Affiliation(s)
- Satoru Motoyama
- Department of Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Kim HC, Pandolfino JE, Komanduri S, Hirano I, Cohen ER, Wayne DB. Use of a continuing medical education course to improve fellows' knowledge and skills in esophageal disorders. Dis Esophagus 2011; 24:388-94. [PMID: 21309911 DOI: 10.1111/j.1442-2050.2010.01161.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Advanced esophageal endoscopic procedures such as stricture dilation, hemostasis tools, and stent placement as well as high-resolution manometry (HRM) interpretation are necessary skills for gastroenterology fellows to obtain during their training. Becoming proficient in these skills may be challenging in light of higher complication rates compared with diagnostic procedures and infrequent opportunities to practice these skills. Our aim was to determine if intensive training during a continuing medical education (CME) course boosts the knowledge and skills of gastroenterology fellows in esophageal diagnostic test interpretation and performance of therapeutic procedures. This was a pretest-posttest design without a control group of a simulation-based, educational intervention in esophageal stricture balloon dilation and HRM interpretation. The participants were 24 gastroenterology fellows from 21 accredited US training programs. This was an intensive CME course held in Las Vegas, Nevada from August 7 to August 9, 2009. The research procedure had two phases. First, the subjects were measured at baseline (pretest) for their knowledge and procedural skill. Second, the fellows received 6 hours of education sessions featuring didactic content, instruction in HRM indications and interpretation, and deliberate practice using an esophageal stricture dilation model. After the intervention, all of the fellows were retested (posttest). A 17-item checklist was developed for the esophageal balloon dilation procedure using relevant sources, expert opinion, and rigorous step-by-step procedures. Nineteen representative HRM swallow studies were obtained from Northwestern's motility lab and formed the pretest and posttest in HRM interpretation. Mean scores on the dilation checklist improved 81% from 39.4% (standard deviation [SD]= 33.4%) at pretest to 71.3% (SD = 29.5%) after simulation training (P < 0.001). HRM mean examination scores increased from 27.2% (SD = 16.4%) to 46.5% (SD = 15.8%), representing a 71% improvement (P < 0.001). Pearson's correlations indicated there was no correlation between pretest performance, medical knowledge measured by United States Medical Licensing Examination examinations, prior clinical experience, or procedural self-confidence and posttest performance of esophageal dilation or HRM interpretation. The education program was rated highly. This study demonstrated that a CME course significantly enhanced the technical skills and knowledge of gastroenterology fellows in esophageal balloon dilation and HRM interpretation. CME courses such as this may be a valuable adjunct to standard fellowship training in gastroenterology.
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Affiliation(s)
- H C Kim
- Department of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Abstract
Esophageal damage is an uncommon manifestation of Crohn's disease. The diagnosis should be considered in patients who have other intestinal manifestations of Crohn's disease and present with esophageal symptoms. Diagnosis should be based on history, known extraesophageal Crohn's disease, endoscopic evaluation with biopsy, and exclusion of gastroesophageal reflux disease. Mild disease should be treated with acid suppression and a short course of steroids. 5-aminosalicylates are not likely to be effective due to drug release characteristics. Patients who have moderate to severe disease should be treated aggressively with acid suppression, a longer course of steroids, and consideration of immunosuppressive therapy with 6-mercaptopurine or azathioprine. Infliximab or other anti-tumor necrosis factor therapy also can be considered in refractory patients to try to prevent the complications of stricturing and fistula formation. In those patients who develop strictures of the esophagus, treatment with balloon dilatation of the stricture followed by injection of a long-acting steroid such as triamcinolone will help to alleviate symptoms. Surgery may be required for severe, refractory symptoms, but it has a high morbidity in this population.
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Affiliation(s)
- Kim L Isaacs
- Kim L. Isaacs, MD, PhD Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, CB# 7032, Room 7200 MBRB, Chapel Hill, NC 27599-7032, USA.
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Honda M, Nakamura T, Hori Y, Shionoya Y, Yamamoto K, Nishizawa Y, Kojima F, Shigeno K. Feasibility study of corticosteroid treatment for esophageal ulcer after EMR in a canine model. J Gastroenterol 2011; 46:866-72. [PMID: 21597933 DOI: 10.1007/s00535-011-0400-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 01/30/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intralesional or systemic steroid administration is a promising strategy for the prevention of esophageal stricture after endoscopic therapy. The aim of this study was to evaluate the influence of steroid therapy on the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR). METHODS Nine beagle dogs were divided into three equal groups: group A, intralesional injection (n = 3), group B, peroral administration (n = 3), and group C, untreated control (n = 3). In group A, triamcinolone acetonide 1 ml (10 mg) was injected directly into the exposed submucosal layer immediately after EMR, and again on postoperative day (POD) 7. In group B, dogs were administered prednisolone 0.5 mg/kg/day orally for 14 days after EMR. In group C, 1 ml normal saline was injected by the same method as that used for group A. On POD 28, histological examination was performed to evaluate epithelialization, inflammation, angiogenesis, and atrophy of the muscularis propria. RESULTS In groups A, B, and C, the mean ulcer area was 50.1, 22.7, and 7.4 mm(2), respectively. The difference between groups A and C was significant (p < 0.01). Inflammatory cells were significantly more evident in the lesions of group A than in those of group C (p < 0.05). In all groups, atrophy of the muscularis propria was evident. However, transmural destruction and fibrosis were observed only in group A. CONCLUSION It was speculated that the esophageal ulcer causes the fibrosis of the submucosa and atrophy of the muscularis propria during process of healing. Intralesional steroid injection deepened the esophageal ulcers and delayed epithelialization, whereas systemic administration did not clearly improve the lesion healing process.
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Affiliation(s)
- Michitaka Honda
- Department of Bioartificial Organs, Institute for Frontier Medical Science, Kyoto University, 53 Kawahara cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Davis PL, Hardison S, Sullivan CA. Topical mithramycin-A modulates submucosal collagen deposition after esophageal burn injury in rats. Otolaryngol Head Neck Surg 2011; 145:435-41. [PMID: 21521900 DOI: 10.1177/0194599811407420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate efficacy of a drug-eluting, dissolvable esophageal (DEDE) stent for the prevention of submucosal collagen deposition in a rat model of acute esophageal injury. SETTING University laboratory. STUDY DESIGN Interventional randomized controlled trial. SUBJECTS AND METHODS Forty two adult, male, age-matched Sprague Dawley rats were randomized to undergo either sham esophageal surgery, esophageal burn injury, or esophageal burn injury and placement of a DEDE stent. All animals underwent open gastrotomy under anesthesia. In group 1, a cautery device was inserted through the gastrotomy into the distal esophagus and removed without creating an injury. In group 2, the cautery was placed in the distal esophagus and a circumferential thermal burn injury was created. In group 3, an identical burn injury was created and a DEDE stent was placed at the site of injury and secured. On postoperative day 28, animals were sacrificed, and the distal esophagi were harvested and processed for histology. Submucosal collagen area was quantified histologically and compared across the 3 experimental groups. RESULTS After the investigators controlled for luminal circumference and multiple measurements, submucosal collagen area was increased in group 2 (burn) compared with group 1 (sham) (P = .012). Submucosal collagen area was decreased in group 3 (DEDE stent) compared with group 2 (P = .042). No statistically significant difference in submucosal collagen area was observed between animals in group 1 and group 3 (P = .800). CONCLUSIONS;Topical application of mithramycin-A via a DEDE stent modulates collagen deposition after acute thermal injury in the rat esophagus.
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Affiliation(s)
- Paul Lawson Davis
- Wake Forest University School of Medicine, Department of Otolaryngology, Winston-Salem, NC, USA
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Marciano R, Speridião PDGL, Kawakami E. Consumo alimentar de crianças e adolescentes com disfagia decorrente de estenose de esôfago: avaliação com base na pirâmide alimentar brasileira. REV NUTR 2011. [DOI: 10.1590/s1415-52732011000200004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Avaliar o consumo alimentar de pacientes com disfagia decorrente de estenose de esôfago, comparando a dieta de consistência líquida com a dieta de consistência pastosa e sólida, com base na Pirâmide Alimentar Brasileira. MÉTODOS: Estudo de corte transversal, no qual foram incluídos consecutivamente 31 pacientes com estenose esofágica, sendo 18 (58,0%) cáustica, 7 (22,6%) pós-cirúrgica, 3 (9,7%) péptica e 3 (9,7%) sem causa definida. Empregou-se o recordatório de 24 horas; os alimentos foram transformados em porções em função dos oito grupos de alimentos, conforme recomendado por Philippi. Utilizou-se o teste Kruskal-Wallis e Exato de Fisher, fixando em 5% o nível de rejeição da hipótese de nulidade. RESULTADOS: A idade variou entre 15 e 176 meses (mediana, 56 meses), sendo 28 crianças e três adolescentes, e 18 do sexo masculino. Vinte e nove pacientes (93,5%) apresentavam disfagia, sendo grave em 34,4% (10/29), moderada em 41,3% (12/29), e leve em 24,1% (7/29). O consumo mediano de porções de cereais, leguminosas, e óleos e gorduras foi menor no grupo com dieta líquida (p<0,005), o qual também apresentou maior proporção de pacientes cujo consumo foi abaixo do proposto pela pirâmide alimentar quando comparado ao grupo com dieta pastosa e sólida, com diferença estatisticamente significante (p<0,05). CONCLUSÃO: O suporte nutricional é de extrema importância no tratamento de pacientes com estenose esofágica, principalmente na disfagia grave, cuja dieta deve ser adaptada à consistência líquida, devido ao risco nutricional que se atribui à limitada ingestão alimentar, e para que o tratamento dietético seja precocemente instituído.
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Honda M, Hori Y, Nakada A, Uji M, Nishizawa Y, Yamamoto K, Kobayashi T, Shimada H, Kida N, Sato T, Nakamura T. Use of adipose tissue-derived stromal cells for prevention of esophageal stricture after circumferential EMR in a canine model. Gastrointest Endosc 2011; 73:777-84. [PMID: 21272874 DOI: 10.1016/j.gie.2010.11.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 11/04/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR is an accepted treatment for early esophageal carcinoma. However, resection of a large mucosal area often causes postoperative esophageal stricture. OBJECTIVE To investigate the efficacy of autologous adipose tissue-derived stromal cells (ADSCs) for prevention of stricture formation after EMR in dogs. DESIGN Animal study. SETTING University research center. INTERVENTION Ten beagle dogs were randomized into a control group and an ADSCs-injected (ADSC) group. The ADSCs were isolated from autologous adipose tissue. Immediately after circumferential esophageal EMR, about 5 × 10(6) ADSCs suspended in 8 mL of phosphate-buffered saline solution were injected endoscopically into the residual submucosa of the ADSC group, whereas the control group received only 8 mL of phosphate-buffered saline solution. MAIN OUTCOME MEASUREMENTS Dysphagia score, weight loss, rate of mucosal constriction, and histologic assessments. RESULTS In the control and ADSC groups, the median dysphagia scores were 4 and 1 (P < .043), the mean degrees of mucosal constriction were 75.7% and 45.3% (P < .008), and the numbers of nascent microvessels in the submucosal layer were 7.4 and 16.2 per unit area (P = .007), respectively. Atrophy and fibrosis of the muscularis propria layer were observed in the control group. LIMITATIONS Animal study, small sample size. CONCLUSION Injection therapy with autologous ADSCs suppresses constriction of the esophageal mucosa and improves clinical symptoms after circumferential EMR in this canine model.
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Affiliation(s)
- Michitaka Honda
- Department of Bioartificial Organs, Institute for Frontier Medical Science, Kyoto University, Kyoto, Japan
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Okata Y, Hisamatsu C, Hasegawa T, Nishijima E, Okita Y. Development of a model of benign esophageal stricture in rats: the optimal concentration of sodium hydroxide for stricture formation. Pediatr Surg Int 2011; 27:73-80. [PMID: 20865264 DOI: 10.1007/s00383-010-2711-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To investigate the optimal concentration of sodium hydroxide (NaOH) on esophageal stricture formation in rats to establish an animal model of benign esophageal stricture (BES). METHODS Corrosive esophageal burn was produced by internal application of different concentrations of NaOH to the distal esophagus in rats. As much as 66 male rats were randomly divided into eight groups: Group A (control, n = 6), Group B (sham-operated group, n = 6), Group C (5% NaOH, n = 8), Group D (10% NaOH, n = 8), Group E (20% NaOH, n = 8), Group F (30% NaOH, n = 10), Group G (40% NaOH, n = 14), and Group H (50% NaOH, n = 6). Surviving rats were killed at 28 days. The survival rate, body weight gain, symptoms, and histopathological changes were assessed. RESULTS The mortality rate was high in Groups G and H (73 and 67%). The prevalence of symptoms of BES was 43% in Groups D and E, 50% in Group F, 75% in Group G, and 100% in Group H. Statistically significant stricture formation of the esophagus was observed in Groups F and G. The degree of tissue damage was significantly higher in Groups E, F, and G. CONCLUSION A high concentration of NaOH of 30% was required to establish a survivable BES model in rats.
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Affiliation(s)
- Yuichi Okata
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan.
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Kamal A, Vaezi MF. Diagnosis and initial management of gastroesophageal complications. Best Pract Res Clin Gastroenterol 2010; 24:799-820. [PMID: 21126695 DOI: 10.1016/j.bpg.2010.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/21/2010] [Accepted: 09/23/2010] [Indexed: 01/31/2023]
Abstract
Chronic esophageal exposure to reflux of gastroduodenal contents can result in complications of GERD including esophageal stricture, Barrett's oesophagus or extraesophageal symptoms such as laryngitis, chronic cough or asthma. Endoscopy is the main diagnostic tool for patients with chronic reflux presenting with dysphagia to visualise esophageal mucosa and identify the underlying pathology. Barrett's oesophagus should be suspected in those with chronic reflux disease. Patients with Barrett's oesophagus should undergo surveillance endoscopy in order to risk stratify to dysplasia or adenocarcinoma. New endoscopic ablative therapies in patients with Barrett's oesophagus and high grade dysplasia are promising new treatment modality for those who may not be candidates for definitive intervention. Given poor sensitivity of diagnostic tests in extraesophageal reflux, empiric therapy with proton pump patients is the initial recommended approach. Diagnostic testing with esophagogastroduodenoscopy and ambulatory pH and impedance monitoring is usually reserved for those unresponsive to acid suppressive therapy. Many uncertainties remain in this group of patients including which patient subgroups might benefit from acid suppressive therapy. Future outcome studies are needed to assess the role of impedance/pH monitoring in this group of patients and to determine who might symptomatically benefit from medical or surgical intervention.
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Affiliation(s)
- Afrin Kamal
- Vanderbilt University Medical Center, Nashville, TN 37232, United States
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Repici A, Vleggaar FP, Hassan C, van Boeckel PG, Romeo F, Pagano N, Malesci A, Siersema PD. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72:927-34. [PMID: 21034894 DOI: 10.1016/j.gie.2010.07.031] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/21/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Benign esophageal strictures refractory to standard dilation therapy present a challenging problem. Temporary plastic and metal stents have been proposed with inconclusive results. OBJECTIVE To evaluate the efficacy and safety of a new biodegradable stent for the treatment of refractory benign esophageal strictures (RBESs). DESIGN AND SETTING Prospective study from 2 European endoscopy centers. PATIENTS AND INTERVENTION Twenty-one patients (11 men/10 women, mean age 60.2 ± 17.6 years) with RBESs defined according to the Kochman criteria treated by placement of a biodegradable stent (Ella stent). MAIN OUTCOME MEASUREMENTS Clinical and endoscopic follow-up was scheduled at 1, 2, 3, and 6 months and later only in case of dysphagia recurrence. Pre- and poststenting dysphagia status was graded according to a 5-point scale. Minor and major complication rates were prospectively assessed. RESULTS Stent insertion was technically successful in all of the patients. At 4 and 7 weeks, stent migration occurred in 2 patients (9.5%). At 3-month endoscopy, the stent appeared to be almost completely fragmented in all remaining patients. The median pre- and poststenting dysphagia scores were 3 (range 3-4) and 1 (range 0-2), respectively (P < .01), with a median follow-up of 53 weeks (range 25-88 weeks). In detail, 9 of 20 patients (45%) were dysphagia free at the end of the follow-up. No major complications occurred. Severe poststenting pain requiring analgesics developed in 3 patients, and minor bleeding was observed in 1 patient. LIMITATIONS Limited follow-up; nonrandomized study. CONCLUSIONS In this preliminary study, the biodegradable stent showed a favorable risk/benefit ratio, achieving complete relief of dysphagia in nearly 50% of RBES patients without the occurrence of major complications. The use of this stent may be a valuable alternative to repeat endoscopic dilation. Larger studies with longer follow-up are needed.
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Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy.
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Kim JH, Shin JH, Song HY. Benign strictures of the esophagus and gastric outlet: interventional management. Korean J Radiol 2010; 11:497-506. [PMID: 20808692 PMCID: PMC2930157 DOI: 10.3348/kjr.2010.11.5.497] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 02/16/2010] [Indexed: 12/16/2022] Open
Abstract
Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy.
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Affiliation(s)
- Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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