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Zerbib F, Bredenoord AJ, Fass R, Kahrilas PJ, Roman S, Savarino E, Sifrim D, Vaezi M, Yadlapati R, Gyawali CP. ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14075. [PMID: 33368919 DOI: 10.1111/nmo.14075] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 02/08/2023]
Abstract
Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.
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Affiliation(s)
- Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | - Ronnie Fass
- Digestive Health Center, MetroHealth System, Cleveland, OH, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Sabine Roman
- Hospices Civils de Lyon, Hôpital E Herriot, Digestive Physiology, Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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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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3
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Badir M, Suissa A, Orlovsky M, Asbeh YA, Khamaysi I. Endoscopic dilation of benign post-esophagectomy anastomotic strictures: long-term outcomes and risk of recurrence. Ann Gastroenterol 2021; 34:337-343. [PMID: 33948058 PMCID: PMC8079862 DOI: 10.20524/aog.2021.0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/18/2020] [Indexed: 12/23/2022] Open
Abstract
Background Benign esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about the factors that affect their remediation. The purpose of this article was to retrospectively evaluate the long-term clinical results of endoscopic dilation in the treatment of benign anastomotic strictures after esophagectomy, and to identify factors associated with stricture recurrence. Methods A single-center retrospective analysis (using electronic records) was performed on patients who underwent endoscopic dilation for esophageal anastomotic strictures. Long-term clinical effectiveness, including technical and clinical success, and complication rate were assessed. Factors independently related to recurrence were evaluated. Results Between January 2014 and December 2017, a total of 35 patients who had benign anastomotic strictures after esophagectomy underwent 182 endoscopic dilation procedures. Technical success was 100%. Thirty-two patients (91%) had initial relief of dysphagia. The clinical success, defined as resolution of dysphagia and achieving luminal patency of 13 mm or more, was achieved in 24 patients (69%). Strictures recurred in 43% of patients, and refractory strictures were identified in 10/35 (29%). Proximal anastomosis and the presence of anastomotic foreign bodies were found to be risk factors for refractory strictures. The complication rate was low (4%) and adverse events were mild. No major complications (perforations, severe bleeding) or treatment-related deaths occurred in this series. Conclusions Endoscopic dilation has a high technical and a good clinical success rate. However, anastomotic strictures are often refractory and frequently recur.
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Affiliation(s)
- Mead Badir
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology (Mead Badir, Iyad Khamaysi)
| | - Alain Suissa
- Department of Gastroenterology (Alain Suissa, Iyad Khamaysi)
| | - Michael Orlovsky
- Department of Chest Surgery, Rambam Health Care Campus (Michael Orlovsky, Yousef Abu Asbeh), Haifa, Israel
| | - Yousef Abu Asbeh
- Department of Chest Surgery, Rambam Health Care Campus (Michael Orlovsky, Yousef Abu Asbeh), Haifa, Israel
| | - Iyad Khamaysi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology (Mead Badir, Iyad Khamaysi).,Department of Gastroenterology (Alain Suissa, Iyad Khamaysi)
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4
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Vermeulen BD, de Zwart M, Sijben J, Soons E, van der Weerd L, Arese D, von den Hoff DW, Craviotto V, Tan ACITL, Groenen MJM, Bogte A, Repici A, Spaander MCW, Siersema PD. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study. Gastrointest Endosc 2020; 91:1058-1066. [PMID: 31917167 DOI: 10.1016/j.gie.2019.12.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED. METHODS We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BESs. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BESs, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints were time from first to last ED session and adverse events. RESULTS Dilation up to 13 to 15 mm was associated with a higher number of ED sessions than dilation up to 16 to 18 mm (5.0 vs 4.1; hazard ratio [HR], 1.4; P = .001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR, 2.1; P < .001), radiation (5.0 vs 3.6; HR, 3.0; P < .001), caustic (7.2 vs 3.6; HR, 2.7; P < .001), and postendotherapy (3.9 vs 3.6; HR, 1.8; P = .005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy, and 62% in caustic strictures. Esophageal perforation occurred in 23 ED sessions (.4%) in 22 patients (2.4%). CONCLUSIONS More than 60% of patients with BESs remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merle de Zwart
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jasmijn Sijben
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elsa Soons
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lucie van der Weerd
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daniele Arese
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daan W von den Hoff
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vincenzo Craviotto
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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5
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Clinical Feasibility and Safety of Endoscopic Self-Expandable Metal Stent Placement for Upper Gastrointestinal Pathologies. Int Surg 2018. [DOI: 10.9738/intsurg-d-15-00169.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to review our experiences to evaluate the practicality, safety, and effectiveness of endoscopic stent placement for the palliation of malignant obstructions of the upper gastrointestinal system (GIS) and the treatment of postoperative complications such as failure of anastomoses and fistulae. Endoscopic stent placement is increasingly used in the upper GIS for the management of both high grade malignancies causing obstruction and benign pathologies such as anastomosis failures, gastrointestinal fistulae, and strictures. Hospital records, clinical data, and endoscopy reports of 61 patients who had undergone endoscopic stenting between the years 2012 and 2015 were analyzed retrospectively. For all patients, self-expandable metal covered stents were used. Data involving technical and clinical success rates, complication, morbidity, and mortality rates of the endoscopic stenting procedure was collected and simple statistical analyses were made. Endoscopic stenting was successful in 60 of 61 patients (98.3%). Overall technical success rate was found to be 98.3%; clinical success rate, 86.6%; complication rate, 4.9%. No stent related mortality was observed in our series. Endoscopic stents can be effectively and safely used in the treatment of various lesions of the upper GIS.
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6
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Bektaş H, Gürbulak B, Düzköylü Y, Çolak Ş, Gürbulak EK, Çakar E, Bayrak S. Clinical Outcomes of Upper Gastrointestinal Stents and Review of Current Literature. JSLS 2017; 21:JSLS.2017.00058. [PMID: 29162972 PMCID: PMC5683815 DOI: 10.4293/jsls.2017.00058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The self-expandable metal stent (SEMS) is an alternative for several possible surgical and palliative treatments of upper gastrointestinal obstructions that occur in several disease states. The present study was performed to describe a single-center experience with upper gastrointestinal stents. METHODS All patients at a single center who had an SEMS placed for the treatment of obstruction over a 3-year period were retrospectively evaluated. Pre- and postoperative dysphagia scoring was calculated and used to evaluate postprocedure improvement in quality of life. Procedural success and early and late complication rates were investigated. RESULTS A total of 171 endoscopic procedures were performed in 73 patients. Procedural success was 95.8% (n = 69) and dilatation was performed in 80 patients. The rate of perioperative complication was 26% (n = 19). After 1 month, stents were patent in all patients (n = 73). Stent obstruction was noted in 6 patients: 2 each at 2, 7, and 10 months. CONCLUSION SEMS usage for palliative and curative purposes in benign or malignant upper gastrointestinal system obstructions is an efficient and reliable treatment method with advantages, such as shortening hospital stay, decreased pain, cost-effectiveness, and low mortality-morbidity rates when compared to surgical procedures, and a high rate of clinical success.
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Affiliation(s)
- Hasan Bektaş
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Bünyamin Gürbulak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yiğit Düzköylü
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Şükrü Çolak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Esin Kabul Gürbulak
- Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ekrem Çakar
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Savaş Bayrak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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7
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Steroid pulse therapy prevents restenosis following balloon dilatation for esophageal stricture. Pediatr Surg Int 2016; 32:875-9. [PMID: 27469501 DOI: 10.1007/s00383-016-3939-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to evaluate the effectiveness of intravenous steroid pulse therapy following balloon dilatation for esophageal stenosis and stricture in children. METHODS The study enrolled six children, including three with congenital esophageal stenosis and three with anastomotic strictures after surgery for esophageal atresia, all of whom were treated by balloon dilatation combined with high-dose intravenous methylprednisolone pulse therapy. Methylprednisolone was injected intravenously at a dose of 20 mg/kg/day for 2 days, starting from the day of dilatation, followed by 10 mg/kg/day for 2 days, for a total of 4 days. RESULTS Esophageal stricture recurred in all three patients with congenital esophageal stenosis despite repeated balloon dilatation without methylprednisolone. However, the symptoms of dysphagia improved and did not recur after systemic steroid pulse therapy following balloon dilatation. Symptoms also resolved in all three patients with anastomotic strictures following balloon dilatation with systemic steroid pulse therapy. All six patients remained asymptomatic after 6-21 months follow-up, with no complications. CONCLUSION Intravenous methylprednisolone pulse therapy following balloon dilatation is safe and effective for the treatment of esophageal stenosis and strictures in children.
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8
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Repici A, Small AJ, Mendelson A, Jovani M, Correale L, Hassan C, Ridola L, Anderloni A, Ferrara EC, Kochman ML. Natural history and management of refractory benign esophageal strictures. Gastrointest Endosc 2016; 84:222-8. [PMID: 26828759 DOI: 10.1016/j.gie.2016.01.053] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/23/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES. METHODS Clinical data of consecutive patients with RBES treated in the previous 15 years in 2 tertiary-care referral academic centers with specialized interest in esophageal stricture management were retrospectively analyzed. RBES was defined as the persistence and/or recurrence of dysphagia despite at least 5 dilation sessions and/or cycles with dilation to at least 14 mm. Information regarding the use of dilation or stents and the dysphagia-free period between subsequent interventions and adverse events was collected. Clinical success was defined as no need for endoscopic interventions for at least 6 months; unfavorable outcomes were defined as the need for endoscopic treatment at the end of follow-up, surgery, or percutaneous endoscopic gastrostomy (PEG). Predictors of unfavorable outcomes were assessed by multivariate analysis. A linear mixed-effect model was used to measure dysphagia-free period changes over time. RESULTS Overall, 70 patients with RBES (46 male; mean age 60 years) were followed for a mean of 43.9 months (range 3.7-157 months). Caustic, postradiotherapy, surgical, mixed, and postinflammatory etiology accounted for 10%, 14.3%, 31.4%, 40%, and 4.3% of causes, respectively. All patients underwent sequential sessions of pneumatic or bougie dilation, with a median of 15.5 dilation sessions per patient. Self-expandable metal stents (SEMSs) and biodegradable stents were placed in 18 (25.7%) and 14 (20%) patients, respectively. RBES resolution was achieved in only 22 of 70 (31.4%) patients. Two deaths (3%) were related to RBES. The success rate was lower in those who also were treated with endoprosthetics (odds ratio [OR] 3.7; 95% confidence interval [CI], 1.01-18.0). The mean dysphagia-free period was 3.3 months (95% CI, 2.4-4.1) for patients treated with dilation and 2.4 months (95% CI, 1.2-3.6) for those treated with stents (P = .062). Over time, the total dysphagia-free period increased at a rate of 4.1 days (95% CI, 1.7-6.4) per dilation. There was no difference in the rate of change across groups defined by sex (P = .976), age (P = .633), or endoscopic treatment (P = .267). CONCLUSIONS Our multicenter series showed a disappointing long-term outcome for RBES, with only 1 of 3 achieving clinical resolution. The dysphagia-free period was relatively short, affecting the quality of life. Endoprosthetics did not appear to affect the natural history of RBES.
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Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy; Humanitas University, Milan, Italy
| | - Aaron J Small
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Aaron Mendelson
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | - Michael L Kochman
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Gangloff A, Lecleire S, Di Fiore A, Huet E, Iwanicki-Caron I, Antonietti M, Michel P. Fully versus partially covered self-expandable metal stents in benign esophageal strictures. Dis Esophagus 2015; 28:678-83. [PMID: 25168061 DOI: 10.1111/dote.12260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Self-expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long-term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self-expandable metal stents (FCSEMS). We performed a retrospective analysis of self-expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty-two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long-term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.
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Affiliation(s)
- A Gangloff
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - S Lecleire
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - A Di Fiore
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - E Huet
- Department ofDigestive Surgery, Rouen University Hospital, Rouen, France
| | - I Iwanicki-Caron
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - M Antonietti
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - P Michel
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
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10
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Mendelson AH, Small AJ, Agarwalla A, Scott FI, Kochman ML. Esophageal anastomotic strictures: outcomes of endoscopic dilation, risk of recurrence and refractory stenosis, and effect of foreign body removal. Clin Gastroenterol Hepatol 2015; 13:263-271.e1. [PMID: 25019695 PMCID: PMC4289652 DOI: 10.1016/j.cgh.2014.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 06/23/2014] [Accepted: 07/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness after dilation and factors associated with refractory stenosis. METHODS We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated during a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions during 10 weeks. RESULTS Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median, 37 days; interquartile range [IQR], 20-82 days) or lengthen the dysphagia-free interval (37.4 days; IQR, 8-41 weeks), compared with patients who did not undergo removal (initial patency, median 55 days; IQR, 14-109 days; P = .66 and median dysphagia-free interval, 21.7 days; IQR, 9-64 weeks; P = .8). Use of fluoroscopy during dilation (odds ratio, 8.92; 95% confidence interval, 1.98-40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio, 0.28; 95% confidence interval, 0.07-0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis. CONCLUSIONS Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.
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Affiliation(s)
- Aaron H Mendelson
- Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aaron J Small
- Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anant Agarwalla
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frank I Scott
- Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael L Kochman
- Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Wilmott Center for Endoscopic Innovation, Research, and Training, Philadelphia, Pennsylvania.
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11
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Dan DT, Gannavarapu B, Lee JG, Chang K, Muthusamy VR. Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES). Dis Esophagus 2014; 27:511-7. [PMID: 23121426 DOI: 10.1111/j.1442-2050.2012.01432.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004-2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty-five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx-E (Merit-Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long-term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.
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Affiliation(s)
- D T Dan
- H.H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology, Department of Medicine, University of California, Irvine Medical Center, Orange, California, USA
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12
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Soumekh A, Schnoll-Sussman FH, Katz PO. Reflux and Acid Peptic Diseases in the Elderly. Clin Geriatr Med 2014; 30:29-41. [DOI: 10.1016/j.cger.2013.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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Manta R, Magno L, Conigliaro R, Caruso A, Bertani H, Manno M, Zullo A, Frazzoni M, Bassotti G, Galloro G. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45:879-85. [PMID: 23623147 DOI: 10.1016/j.dld.2013.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/28/2013] [Accepted: 03/09/2013] [Indexed: 12/11/2022]
Abstract
Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Endoscopy Unit, New S. Agostino Hospital, Modena, Italy.
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15
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Hucl T. Acute GI obstruction. Best Pract Res Clin Gastroenterol 2013; 27:691-707. [PMID: 24160928 DOI: 10.1016/j.bpg.2013.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 02/07/2023]
Abstract
Acute gastrointestinal obstruction occurs when the normal flow of intestinal contents is interrupted. The blockage can occur at any level throughout the gastrointestinal tract. The clinical symptoms depend on the level and extent of obstruction. Various benign and malignant processes can produce acute gastrointestinal obstruction, which often represents a medical emergency because of the potential for bowel ischemia leading to perforation and peritonitis. Early recognition and appropriate treatment are thus essential. The typical clinical symptoms associated with obstruction include nausea, vomiting, dysphagia, abdominal pain and failure to pass bowel movements. Abdominal distention, tympany due to an air-filled stomach and high-pitched bowel sounds suggest the diagnosis. The diagnostic process involves imaging including radiography, ultrasonography, contrast fluoroscopy and computer tomography in less certain cases. In patients with uncomplicated obstruction, management is conservative, including fluid resuscitation, electrolyte replacement, intestinal decompression and bowel rest. In many cases, endoscopy may aid in both the diagnostic process and in therapy. Endoscopy can be used for bowel decompression, dilation of strictures or placement of self-expandable metal stents to restore the luminal flow either as a final treatment or to allow for a delay until elective surgical therapy. When gastrointestinal obstruction results in ischemia, perforation or peritonitis, emergency surgery is required.
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Affiliation(s)
- Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Videnska 9, 140 21 Prague 4, Czech Republic.
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Promberger R, Lenglinger J, Riedl O, Seebacher G, Eilenberg W, Ott J, Riegler F, Gadenstätter M, Neumayer C. Gastro-oesophageal reflux disease in type 2 diabetics: symptom load and pathophysiologic aspects - a retro-pro study. BMC Gastroenterol 2013; 13:132. [PMID: 23972125 PMCID: PMC3765380 DOI: 10.1186/1471-230x-13-132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 08/14/2013] [Indexed: 12/15/2022] Open
Abstract
Background Information about gastro-oesophageal reflux disease (GERD) in patients with Diabetes mellitus type 2 (T2D) is scarce, although the incidence of both disorders is increasing. We aimed to determine GERD symptoms and their underlying pathophysiologic characteristics in T2D patients. Methods This “retro-pro” study compared 65 T2D patients to a control group of 130 age- and sex-matched non-diabetics. GERD was confirmed by gastroscopy, manometry, pH-metry and barium swallow. Results In patients with T2D compared to controls, dysphagia (32.3% vs. 13.1%; p = 0.001) and globus sensation (27.7% vs. 13.8%; p = 0.021) were found more frequently, whereas heartburn (76.9% vs. 88.5%; p = 0.046) and regurgitation (47.7% vs. 72.3%; p = 0.001) were predominant in non-diabetics. Despite higher body mass indices (31.1 ± 5.2 vs. 27.7 ± 3.7 kg/m2; p < 0.001), hiatal hernia was less frequent in T2D patients compared to controls (60.0% vs. 90.8%, p < 0.001). Lower oesophageal sphincter (LES) pressure was higher in patients with T2D (median 10.0 vs. 7.2 mmHg, p = 0.016). DeMeester scores did not differ between the groups. Helicobacter pylori infections were more common in T2D patients (26.2% vs. 7.7%, p = 0.001). Barrett metaplasia (21.5% vs. 17.7%), as well as low- (10.8% vs. 3.8%) and high-grade dysplasia (1.5% vs. 0%) were predominant in T2D patients. Conclusions T2D patients exhibit different GERD symptoms, higher LES pressures and a decreased prevalence of hiatal hernia than non-diabetics, which may be related to worse oesophageal motility and, thus, a more functional rather than anatomical cause of GERD. Low-grade dysplasia was more than twice as high in T2D than in non-diabetics patients. Trial registration Ethics committee of the Medical University of Vienna, IRB number 720/2011.
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Efficacy of intralesional corticosteroid injection in endoscopic treatment of esophageal strictures. Surg Laparosc Endosc Percutan Tech 2013; 22:518-22. [PMID: 23238379 DOI: 10.1097/sle.0b013e3182747b31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The present study was conducted to determine the effectiveness of intralesional triamcinolone to improve the results of endoscopic dilation in esophageal strictures. METHODS We treated 9 patients with complex strictures of different etiologies (2 postsurgery, 3 gastroesophageal reflux disease, and 4 caustic) with intralesional injections of triamcinolone followed by endoscopic dilations. Outcomes of triamcinolone-treated patients were compared with those of historical control. We injected triamcinolone before dilating the strictures. All the patients were followed up for 1 year. The interval between dilations, frequency of dilation, and refractory rates were calculated. RESULTS There was no difference between the control group and the patients with steroids regarding baseline characteristics (age and sex distribution of patients and stricture etiologies, length, and location). The patients in the triamcinolone group had a bigger improvement of their dysphagia and had a lower refractority rate than the patients in control group, these differences being statistically significant. CONCLUSIONS Intralesional triamcinolone presented a higher improvement of dysphagia and a lower refractority rate in patients with complex strictures with statistically significant differences.
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A pilot study of scheduled endoscopic balloon dilation with oral agent tranilast to improve the efficacy of stricture dilation after endoscopic submucosal dissection of the esophagus. J Clin Gastroenterol 2012; 46:e76-82. [PMID: 22955264 DOI: 10.1097/mcg.0b013e31824fff76] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS AND AIM As circumferential or near-circumferential endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms might evoke refractory strictures, multiple sessions of endoscopic balloon dilation (EBD) are required. We aimed to assess the effectiveness and safety of oral agent tranilast with EBD for improving the efficacy of stricture dilation after esophageal ESD. METHODS In an open-label prospective study at a single institution, 31 asymptomatic consecutive patients with superficial esophageal squamous cell carcinomas were enrolled from April 2007 to October 2010. After ESD, we performed scheduled EBD (twice weekly for 4 wk) with or without administration of oral agent tranilast for 8 weeks. Thereafter, we added additional EBD on the basis of solid criteria-for example, patient's awareness of vomiting >1/wk and inability of passage of routine endoscope through the ESD site. We compared the rates of post-ESD strictures and the numbers of additional EBD sessions for 48 weeks after ESD and the Dysphagia score between tranilast (T)-group and none (N)-group, based on patients' subjective symptoms, at 16, 24, and 48 weeks after ESD. RESULTS The percentage of post-ESD strictures in T-group was significantly lower than that in N-group (P=0.04). The median numbers of additional EBD sessions and Dysphagia score at 16 and 24 weeks after ESD in T-group were significantly smaller than those in N-group (P=0.0138, 0.002, 0.005, respectively). No adverse events and no recurrence were observed. CONCLUSIONS We demonstrated for the first time that scheduled EBD combined with oral agent tranilast might be effective and safe for improving the efficacy of stricture dilation after esophageal ESD.
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Peng S, Xiao YL, Cui Y, Lin JK, Zhang N, Hu PJ, Chen MH. High-dose esomeprazole is required for intraesophageal acid control in gastroesophageal reflux disease patients with hiatus hernia. J Gastroenterol Hepatol 2012; 27:893-8. [PMID: 22098387 DOI: 10.1111/j.1440-1746.2011.06969.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to assess whether the efficacy of proton pump inhibitors (PPI) therapy at a standard dose in esophageal acid control is affected by the presence of hiatus hernia in Chinese gastroesophageal reflux disease patients, and whether a higher dose of PPI is required for acid control. METHODS Consecutive gastroesophageal reflux disease patients who had typical reflux symptoms and abnormal baseline 24-h esophageal pH and underwent upper endoscopy were enrolled to receive esomeprazole at 40 mg once daily for 4 weeks. Patients underwent the dual-channel 24-h pH test at the end of 4-week therapy. If the 24-h esophageal pH was still abnormal at the end of 4-week therapy, then esomeprazole at 40 mg twice daily was given for another 4 weeks after a washout interval of 1 week, and a 24-h pH test was repeated at the end of the therapy. RESULTS Overall, 76 patients were included, 13 with hiatus hernia. Of the 76 patients treated with a 40 mg of esomeprazole daily, esophageal acid exposure was normalized in 64 (84.2%). Normalization of acid exposure was achieved by standard PPI therapy in 53.2% (7/13) of patients with hiatus hernia and 90.5% (57/63) of those without (P = 0.004). A double dose of esomeprazole was successful in normalizing the esophageal pH in all 12 non-responders to the standard dose of esomeprazole, including the six patients with hiatus hernia and six patients without. CONCLUSIONS The standard-dose of esomeprazole fails to normalize the esophageal pH in almost 50% of patients with hiatus hernia, in whom the "double-dose" esomeprazole therapy is required.
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Affiliation(s)
- Sui Peng
- Division of Gastroenterology & Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Hirdes MMC, Vleggaar FP, Siersema PD. Stent placement for esophageal strictures: an update. Expert Rev Med Devices 2012; 8:733-55. [PMID: 22029470 DOI: 10.1586/erd.11.44] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.
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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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Liu J, Hu Y, Cui C, Li Y, Lin X, Fu J. Removable, Fully Covered, Self-expandable Metal Stents for the Treatment of Refractory Benign Esophagogastric Anastomotic Strictures. Dysphagia 2011; 27:260-4. [DOI: 10.1007/s00455-011-9361-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 07/21/2011] [Indexed: 01/17/2023]
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van Boeckel PGA, Vleggaar FP, Siersema PD. A comparison of temporary self-expanding plastic and biodegradable stents for refractory benign esophageal strictures. Clin Gastroenterol Hepatol 2011; 9:653-9. [PMID: 21586341 DOI: 10.1016/j.cgh.2011.04.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 03/27/2011] [Accepted: 04/05/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is a challenge to manage refractory benign esophageal strictures (RBES). We compared the efficacy and safety of self-expanding plastic stents (SEPSs) with placement of biodegradable stents for the treatment of RBES. METHODS We studied 2 groups of consecutive patients with RBES who received temporary placement (6 weeks) of SEPSs (n = 20) or biodegradable stents (n = 18). Data were collected with respect to clinical outcome, complications, recurrent dysphagia, and reinterventions. RESULTS SEPSs were removed in 16 (80%) patients. Stent placement was not successful in 1 patient, while stent removal was not performed in another 3 patients. Six (30%) patients with an SEPS were dysphagia-free after a median follow-up of 385 days (range, 77-924 days). Ten (50%) developed recurrent dysphagia. Major complications occurred in 2 patients (10%; 1 with hemorrhage and 1 with perforation). Six patients (33%) with a biodegradable stent were dysphagia-free after a median follow-up of 166 days (range 21-559 days) (P = .83 compared with SEPS). Twelve patients (67%) had recurrent dysphagia. Major complications occurred in 4 patients (22%; 2 with hemorrhage, 2 with severe retrosternal pain) with a biodegradable stent (P = .30 compared with SEPS). Reinterventions were less frequently indicated after biodegradeble stent than after SEPS placement (15 [mean, 0.8 ± 0.6 per stent placed] vs 21 [mean, 1.3 ± 0.4 per stent placed], respectively; P = .03). CONCLUSIONS Placement of SEPSs or biodegradable stents provides long-term relief of dysphagia in 30% and 33%, respectively, of patients with RBES. Biodegradable stents require fewer procedures than SEPSs, offering an advantage. Although stent placement is a viable strategy in patients with RBES, the ideal strategy still needs to be defined.
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, the Netherlands.
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Eloubeidi MA, Talreja JP, Lopes TL, Al-Awabdy BS, Shami VM, Kahaleh M. Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos). Gastrointest Endosc 2011; 73:673-81. [PMID: 21272871 DOI: 10.1016/j.gie.2010.11.014] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 11/08/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases. OBJECTIVE To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases. DESIGN Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity. SETTING Two tertiary care centers with long-standing experience in the management of benign esophageal strictures. PATIENTS Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations. INTERVENTION Temporary placement of FCSEMS until stricture resolution. MAIN OUTCOME MEASUREMENTS Clinical response, efficacy, and morbidity. RESULTS Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications. CONCLUSION Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.
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Affiliation(s)
- Mohamad A Eloubeidi
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Heran MKS, Pham TH, Butterworth S, Robinson A. Use of a microporous polytetrafluoroethylene catheter balloon to treat refractory esophageal stricture: a novel technique for delivery of mitomycin C. J Pediatr Surg 2011; 46:776-779. [PMID: 21496555 DOI: 10.1016/j.jpedsurg.2010.11.030] [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: 07/31/2010] [Revised: 11/09/2010] [Accepted: 11/18/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Endoluminal application of mitomycin C shows promise as a nonsurgical approach to treating recalcitrant stricture but requires precise delivery to prevent mitomycin-mediated injury to adjacent normal mucosa. We describe a novel technique that uses a microporous polytetrafluoroethylene catheter balloon to endoluminally deliver mitomycin C to the target tissue while minimizing nontarget drug application. MATERIALS AND METHODS A newborn infant with proximal tracheoesophageal fistula and distal atresia underwent an uncomplicated repair. However, he developed recurrent esophageal stricture resistant to multiple attempts at pneumatic dilations. An image-guided endoluminal radiologic approach that uses microporous polytetrafluoroethylene catheter balloon was developed to precisely deliver mitomycin C to the mucosal lining of the stricture post-dilation. RESULTS After uncomplicated pneumatic dilation under fluoroscopic guidance, we used a microporous balloon catheter to endoluminally deliver mitomycin C topically to the mucosa at the level of stricture. Three weeks post procedure, repeat esophagram showed resolution of the stricture with unobstructed flow of contrast material to the stomach. The patient had no observable side effects from mitomycin C application. CONCLUSION Image-guided therapies based on balloon dilation and drug-eluting microporous balloon techniques offer a safe, precise, and comprehensive approach to the treatment of recalcitrant esophageal strictures.
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Affiliation(s)
- Manraj K S Heran
- Department of Radiology, BC Children's Hospital, Vancouver, Canada V6H 3V4.
| | - Tuan H Pham
- Division of Pediatric Surgery, Cardon Children's Medical Center, Mesa, AZ, USA
| | - Sonia Butterworth
- Division of Pediatric Surgery, BC Children's Hospital, Vancouver, BC, Canada V6H 3V4
| | - Ashley Robinson
- Department of Radiology, BC Children's Hospital, Vancouver, Canada V6H 3V4
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Bansal A, Kahrilas PJ. Treatment of GERD complications (Barrett's, peptic stricture) and extra-oesophageal syndromes. Best Pract Res Clin Gastroenterol 2010; 24:961-8. [PMID: 21126707 PMCID: PMC3006235 DOI: 10.1016/j.bpg.2010.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 09/23/2010] [Indexed: 01/31/2023]
Abstract
Apart from typical reflux symptoms and oesophagitis, the clinical presentation of GERD can be dominated by mucosal complications of reflux (Barrett's oesophagus, oesophageal adenocarcinoma, Peptic structure) or by extra-oesophageal syndromes, most notably asthma, laryngitis, or chronic cough. Managing these entities is much less straightforward than with oesophagitis. With respect to adenocarcinoma, metaplasia and dysplasia are recognised precursors, but the potential of these lesions to evolve to cancer has not been shown to lessen as a result of treatment, medical or surgical. Consequently, management focuses on strategies to identify and eliminate high-grade dysplasia and intramucosal cancer, lesions that are potentially curable by endoscopic ablation or surgical resection. With respect to the extra-oesophageal GERD syndromes, these are increasingly recognised as multifactorial conditions with reflux as an exacerbating factor. Treatment trials have been generally disappointing and the clinical challenge remains in accurately identifying afflicted patients who might benefit from more intensive medical or surgical reflux treatment.
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Affiliation(s)
- Ajay Bansal
- Department of Medicine, Veterans Affairs Medical Center and University of Kansas, Kansas City, MO
| | - Peter J. Kahrilas
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL
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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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Vleggaar FP, Siersema PD. Stents for benign esophageal strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2011.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Kochhar R, Poornachandra KS. Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc 2010; 2:61-8. [PMID: 21160692 PMCID: PMC2999060 DOI: 10.4253/wjge.v2.i2.61] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Revised: 09/07/2009] [Accepted: 09/15/2009] [Indexed: 02/05/2023] Open
Abstract
Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.
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Affiliation(s)
- Rakesh Kochhar
- Rakesh Kochhar, Kuchhangi Suresh Poornachandra, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Tan VP, Wong BC. Short segment hiatal hernia - the long and the short of it. J Neurogastroenterol Motil 2010; 16:1-2. [PMID: 20535318 PMCID: PMC2879833 DOI: 10.5056/jnm.2010.16.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 12/28/2009] [Indexed: 11/20/2022] Open
Affiliation(s)
- Victoria Py Tan
- Department of Medicine and Center for Cancer Research, University of Hong Kong, Hong Kong
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Hitch your wagon to a star-shaped incision? A closer look at electro-incision for benign gastroesophageal anastomotic strictures. Gastrointest Endosc 2009; 70:856-9. [PMID: 19879401 DOI: 10.1016/j.gie.2009.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 04/12/2009] [Indexed: 12/21/2022]
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Beaumont H, Smout A, Aanen M, Rydholm H, Lei A, Lehmann A, Ruth M, Boeckxstaens G. The GABA(B) receptor agonist AZD9343 inhibits transient lower oesophageal sphincter relaxations and acid reflux in healthy volunteers: a phase I study. Aliment Pharmacol Ther 2009; 30:937-46. [PMID: 19650825 DOI: 10.1111/j.1365-2036.2009.04107.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transient lower oesophageal sphincter relaxations (TLESRs) represent an interesting target for the treatment of gastro-oesophageal reflux. Baclofen reduces TLESRs and reflux episodes, but is not optimal for clinical application because of its central side effects. Therefore, new agents are required. AIM To study the effect of AZD9343, a new selective GABA(B) receptor agonist, in healthy volunteers. METHODS A total of 27 subjects participated in a placebo-controlled, randomized, two-centre phase I study. Subjects underwent oesophageal manometry and pH-metry for 3 h postprandially. Before meal ingestion, a single oral dose of placebo, 60 and 320 mg AZD9343 or 40 mg baclofen was given on four separate days. RESULTS Somnolence was reported after 320 mg AZD9343 and baclofen. Reversible short-lasting paraesthesia was reported after AZD9343. AZD9343 320 mg and baclofen significantly reduced the number of TLESRs with 32% and 40% respectively. Acid reflux was significantly decreased by AZD9343 and baclofen. Like baclofen, AZD9343 increased LES pressure before meal intake. AZD9343 320 mg and baclofen significantly reduced the swallowing rate. CONCLUSIONS Like baclofen, AZD9343 dose-dependently decreases the number of TLESRs and acid reflux episodes, increases LES pressure and reduces swallowing, extending the concept that GABA(B) agonists are potent reflux inhibitors. However, discovery of analogues with an improved side effect profile is warranted.
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Affiliation(s)
- H Beaumont
- Academic Medical Centre, Amsterdam, The Netherlands
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Hordijk ML, van Hooft JE, Hansen BE, Fockens P, Kuipers EJ. A randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures. Gastrointest Endosc 2009; 70:849-55. [PMID: 19573869 DOI: 10.1016/j.gie.2009.02.023] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 02/19/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Benign gastroesophageal anastomotic strictures are common and often refractory to treatment. Various endoscopic dilation techniques have been reported, but none of these methods has been proven to be superior. OBJECTIVE Comparison of the efficacy and safety of dilation of previously untreated anastomotic strictures by using electrocautery incision (EI) and Savary bougienage (SB). DESIGN Randomized, prospective study. SETTING Multicenter study. PATIENTS Sixty-two patients with an anastomotic stricture after esophagogastrostomy and dysphagia Atkinson grades II to IV were included. INTERVENTIONS Patients were treated with EI or SB. MAIN OUTCOME MEASUREMENTS Objective and subjective results were compared with baseline and 1, 3, and 6 months after the first treatment. Complications of both treatments were noted. Primary endpoints after 6 months were the mean number of dilation sessions and success rate (percentage of patients with < or =5 dilations in 6 months). Study participation ended after 6 months or if dysphagia grades II to IV recurred despite 5 treatment sessions. RESULTS No complications occurred with both treatments. There was no significant difference between the EI and SB groups in the mean number of dilations (2.9; 95% CI, 2.7-4.1 vs 3.3; 95% CI, 2.3-3.6l; P = .46) or the success rate (80.6% vs 67.7%, P = .26 and 96.2% vs 80.8%, P = .19). LIMITATIONS In a small study with negative primary endpoints, secondary endpoints and subgroup analyses are hypothesis generating only. CONCLUSIONS This prospective trial demonstrated that EI of gastroesophageal anastomotic strictures is a safe therapy and equivalent to SB as a primary therapy. EI can be used as an alternative or additional therapy to SB. (Registered with Current Controlled Trials, Ltd, registration number ISRCTN81239664.).
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Affiliation(s)
- Marjan L Hordijk
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Bissett SA, Davis J, Subler K, Degernes LA. Risk factors and outcome of bougienage for treatment of benign esophageal strictures in dogs and cats: 28 cases (1995–2004). J Am Vet Med Assoc 2009; 235:844-50. [DOI: 10.2460/javma.235.7.844] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Successful treatment of severe refractory anastomotic stricture in an infant after esophageal atresia repair by endoscopic balloon dilation combined with systemic administration of dexamethasone. Pediatr Surg Int 2009; 25:531-3. [PMID: 19430800 DOI: 10.1007/s00383-009-2367-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2009] [Indexed: 10/20/2022]
Abstract
A boy with a history of esophageal atresia repair received an esophagoesophagostomy at 14 months for a severe refractory anastomotic stricture, which had already required repeated balloon dilation with intralesional dexamethasone injection. Anastomotic leakage and stricture was again evident after the second surgery, and the patient underwent five procedures of balloon dilations with intralesional dexamethasone injection. Dysphagia was persistent and the patient required dilation every 2-3 weeks. After the sixth dilation, the patient was given 1 mg/kg per day of dexamethasone i.v. for 3 days. Dexamethasone i.v. was tapered during the following 3 days and finished at day 6. A week later, endoscopic findings showed an apparent improvement in the stricture. Another dilation was followed by 1 mg/kg per day dexamethasone i.v. for 7 days, and 0.75 kg/mg per day oral dexamethasone for another 7 days. The stricture improved completely and the anastomosis was patent after the second dilation. The patient is doing well without dysphagia and has not required additional dilation for over 18 months after the last dilation. Balloon dilation in combination with systemic dexamethasone administration may be an effective treatment that could substitute invasive techniques including surgical manipulation for severe refractory strictures.
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Hachiya A, Chheda NN, Postma GN. Large Mixed Hiatal Hernia and Stricture as a Cause of Dysphagia. EAR, NOSE & THROAT JOURNAL 2009. [DOI: 10.1177/014556130908800306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Adriana Hachiya
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Medical College of Georgia, Augusta
| | - Neil N. Chheda
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Medical College of Georgia, Augusta
| | - Gregory N. Postma
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Medical College of Georgia, Augusta
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Dua KS, Vleggaar FP, Santharam R, Siersema PD. Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study. Am J Gastroenterol 2008; 103:2988-94. [PMID: 18786110 DOI: 10.1111/j.1572-0241.2008.02177.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed. AIM To evaluate the efficacy of PS in the treatment of RBES. METHODS Forty patients with RBES [mean age 60 +/- 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected. RESULTS The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 +/- 0.7 SD, which was significantly better than pre-stent scores (3.0 +/- 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11-156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding. CONCLUSIONS It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Hasan M, Maple JT. Traversing Difficult Esophageal Strictures from the Retrograde Approach. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Endoscopic dilation of benign esophageal strictures in a surgical unit: a report on 95 cases. Surg Laparosc Endosc Percutan Tech 2008; 17:477-81. [PMID: 18097303 DOI: 10.1097/sle.0b013e3181514217] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Ninety-five patients were treated by endoscopic dilation without fluoroscopic guidance between 1997 and 2005 for benign esophageal strictures. The etiologies were: anastomotic (38), postfundoplication (13), caustic (14), peptic (11), radiation-induced (10) and others (9). The strictures were classified at every session on a 0 to 4 scale on the basis of the diet and the luminal diameter. Savary-Gillard or Through-the Scope balloon dilators were used depending on the type and the location of the stenosis. A total of 472 dilation sessions were carried out without serious complications. A normal and a semisolid diet were respectively achieved in 75% and 91%. Recurrence of dysphagia was found in 33% and 51% of the patients respectively after 2 months and 1 year. Improvement of dysphagia, the number of sessions, and recurrence were significantly better in the patients with postsurgical stenosis as compared with those affected by caustic, peptic, and radiation-induced strictures.
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Kochman ML. Removable endoprosthetics in the management of esophageal pathology: all strictures and fistulae are not created equal.. Gastrointest Endosc 2008; 67:26-7. [PMID: 18155421 DOI: 10.1016/j.gie.2007.08.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 08/20/2007] [Indexed: 02/08/2023]
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Piotet E, Escher A, Monnier P. Esophageal and pharyngeal strictures: report on 1,862 endoscopic dilatations using the Savary-Gilliard technique. Eur Arch Otorhinolaryngol 2007; 265:357-64. [PMID: 17899143 DOI: 10.1007/s00405-007-0456-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 09/10/2007] [Indexed: 02/06/2023]
Abstract
Treatment of symptomatic pharyngeal and esophageal strictures requires endoscopic dilatation. The Savary-Gilliard bougienage was developed by our department and has been used since 1980 for this purpose. We report our experience using this technique. The records of patients seen from January 1, 1963 to December 31, 2005, who had pharyngeal and esophageal strictures needing dilatation, were reviewed. The prevalence of different etiologies, and the incidence of complications using the Savary-Gilliard dilators were assessed. Efficiency of dilatation was assessed over a 17-year segment of this period, using number of dilatations and time intervals between dilatations until resolution of symptoms as outcome measures. Of the 2,652 pharyngeal and esophageal strictures reviewed, 90% were of organic origin (45% benign and 55% malignant stenoses), and 10% were of functional etiology. The most common etiologies were peptic strictures before the era of proton pump inhibitors, and postoperative anastomotic strictures thereafter. A total of 1,862 dilatations using the Savary-Gilliard technique were analyzed. Complication and mortality rates were 0.18 and 0.09% for benign and 4.58 and 0.81% for malignant etiologies, respectively. The number of dilatations per stricture and the time interval between different sessions were dependent on the type of strictures, varying from 1 to 23 dilatations and 7 days to 16 years, respectively. Pharyngeal and esophageal dilatations using the Savary-Gilliard technique were safe when used together with fluoroscopy. Overall, the efficiency of the dilatation procedure was good, but some types of strictures (e.g., caustic, post-surgical and/or post radiotherapy) were refractory to treatment and required repeated dilatations.
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Affiliation(s)
- Elsa Piotet
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Lausanne, 1011 Lausanne, Switzerland.
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Conio M, Blanchi S, Filiberti R, Repici A, Barbieri M, Bilardi C, Siersema PD. A modified self-expanding Niti-S stent for the management of benign hypopharyngeal strictures. Gastrointest Endosc 2007; 65:714-20. [PMID: 17383472 DOI: 10.1016/j.gie.2007.02.050] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The management of patients with refractory hypopharyngeal strictures after surgery in combination with radiation therapy is disappointing, and nutrition through feeding tubes is often required. OBJECTIVE To evaluate the efficacy and safety of a modified self-expanding Niti-S metal stent in the treatment of hypopharyngeal strictures after combined therapy for laryngeal cancer. DESIGN Case series. SETTING A general hospital and a university hospital. PATIENTS Seven consecutive patients were included. One of them did not have laryngectomy. INTERVENTIONS All patients received a modified Niti-S stent. MAIN OUTCOME MEASUREMENTS Improvement of dysphagia, avoiding periodic bougienage, and enteral nutrition through feeding tubes. RESULTS After placement of the first stent, dysphagia improved in all patients. Six of 7 patients developed stent migration and/or granulomatous tissue ingrowth or overgrowth. Additional stents were placed in all patients after a median of 3 months after the previous stent placement. One patient developed an esophagorespiratory fistula caused by a Polyflex stent. Two patients died of causes unrelated to the stent. The remaining 5 patients remained alive and asymptomatic after a median follow-up of 10 months. LIMITATIONS Periodic stent exchange. Stent placement did not resolve the stricture definitively. We had a limited number of patients and have no long-term outcome data yet. CONCLUSIONS The use of this modified Niti-S stent avoids both enteral nutrition through feeding tubes and the need for periodic bougienage in patients with difficult-to-treat benign hypopharyngeal strictures.
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Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy
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Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S. Esophageal stricture: incidence, treatment patterns, and recurrence rate. Am J Gastroenterol 2006; 101:2685-92. [PMID: 17227515 DOI: 10.1111/j.1572-0241.2006.00828.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to determine the incidence, natural history, and recurrence rate of esophageal stricture diagnosed in primary care. METHODS From the U.K. General Practice Research Database, we identified patients with a stricture diagnosis recorded between 1994 and 2000. Diagnoses were confirmed by general practitioner-completed questionnaires. Patients with stricture were compared to an age- and sex-matched sample of controls from the original source population. We estimated the incidence of stricture, potential risk factors, and comorbidities, and relative risk (RR) for subsequent stricture recurrence and mortality. RESULTS The incidence of esophageal stricture was 1.1 per 10,000 person-years and increased markedly with age. Incidence of stricture decreased from 1994 to 2000, concomitant with a substantial increase in proton pump inhibitor (PPI) use. The majority of stricture cases (68%) were peptic. Prior dysphagia, gastroesophageal reflux disease (GERD), hiatus hernia, peptic ulcer disease, and heavy alcohol use were associated with an increased risk of stricture. The rate of stricture recurrence was 11.1 per 100 person-years. Risk of recurrence associated with long-term PPI use adjusting for other factors was 0.6 (95% CI 0.3-1.1). Mortality in patients with peptic stricture was similar to that in the control population. CONCLUSIONS Esophageal stricture is a rare event, and most cases in primary care are peptic strictures. Prior GERD, hiatus hernia, and peptic ulcer are associated with an increased risk of peptic stricture. Incidence of stricture decreased from 1994 to 2000.
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Affiliation(s)
- Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
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Egan JV, Baron TH, Adler DG, Davila R, Faigel DO, Gan SL, Hirota WK, Leighton JA, Lichtenstein D, Qureshi WA, Rajan E, Shen B, Zuckerman MJ, VanGuilder T, Fanelli RD. Esophageal dilation. Gastrointest Endosc 2006; 63:755-60. [PMID: 16650533 DOI: 10.1016/j.gie.2006.02.031] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Shah JN. Benign refractory esophageal strictures: widening the endoscopist's role. Gastrointest Endosc 2006; 63:164-7. [PMID: 16377341 DOI: 10.1016/j.gie.2005.08.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Accepted: 08/29/2005] [Indexed: 12/10/2022]
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Abstract
Patients with progressive or solid food dysphagia should be evaluated for the presence of an esophageal stricture. Barium esophagram and endoscopy can define strictures as benign or malignant. The majority of benign strictures are acid-related. Benign strictures are best managed by esophageal dilation with acid-suppressing medications if a peptic stricture is suspected. If dysphagia recurs, repeat dilation should be performed. There are a variety of interventions for refractory strictures which include injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents and surgery.
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Sgouros SN, Vlachogiannakos J, Karamanolis G, Vassiliadis K, Stefanidis G, Bergele C, Papadopoulou E, Avgerinos A, Mantides A. Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki's) rings: a prospective, randomized, placebo-controlled study. Am J Gastroenterol 2005; 100:1929-34. [PMID: 16128935 DOI: 10.1111/j.1572-0241.2005.41184.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Distal esophageal (Schatzki's) rings are a frequent cause of dysphagia. Bougienage is generally effective, but relapses are common. The aim of this study was to evaluate the effect of long-term antisecretory therapy on the relapse rate of lower esophageal rings after successful bougienage with Savary dilators. PATIENTS AND METHODS The study was performed on 44 consecutive patients with symptomatic Schatzki's rings, detected endoscopically, and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session. After appropriate assessment with esophageal manometry and 24-h ambulatory esophageal pH monitoring, patients with documented GERD (n = 14) were treated with long-term omeprazole therapy. The remaining patients were blindly randomized to receive maintenance treatment with either omeprazole (group A-15 patients) or placebo (group B-15 patients). The necessity for redilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. The relapse rate was evaluated in all groups. RESULTS All bougienages were performed without significant side effects. Eight patients (8 of 44, 18.2%) had one or more relapses after a mean (SD) of 19.0 (10.1) months. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, cigarette and alcohol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There were no recurrences of Schatzki's ring in the group of patients with documented GERD (follow-up [mean +/- SD]: 43.8 +/- 9.3 months, range: 27-62). In group A (follow-up [mean +/- SD]: 37.1 +/- 17.1 months, range: 11-66), one patient relapsed after 13 months, while in group B (follow-up [mean +/- SD]: 34.3 +/- 14.6 months, range: 10-58), seven patients relapsed after a mean (SD) of 19.9 (10.6) months. The actuarial probability of relapse was higher in patients without therapy (group B) (p= 0.008). CONCLUSIONS Our data support the hypothesis that, in patients with symptomatic Schatzki's rings, acid suppressive maintenance therapy after bougienage may prevent relapse of the ring.
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Affiliation(s)
- Spiros N Sgouros
- Department of Gastroenterology, Athens Naval and Veterans Hospital, Athens, Greece
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Cappell MS. Clinical presentation, diagnosis, and management of gastroesophageal reflux disease. Med Clin North Am 2005; 89:243-91. [PMID: 15656927 DOI: 10.1016/j.mcna.2004.08.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
GERD is ubiquitous throughout the adult population in the United States. It commonly adversely affects quality of life and occasionally causes life-threatening complications. The new and emerging medical and endoscopic therapies for GERD and the new management strategies for BE should dramatically reduce the clinical toll of this disease on society.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141-3098, USA.
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