Esophageal rupture during balloon dilation of strictures of benign or malignant causes: prevalence and clinical importance

Balloon dilatation complications during esophagogastric anastomotic stricture treatment under fluoroscopy: Risk factors, prevention, and management

BACKGROUND

Balloon dilatation (BD) is a common treatment for esophagogastric anastomotic stricture (EAS), but with complications. This study investigates the risk factors, prevention, and management of BD complications to provide clinical guidance.

METHODS

We retrospectively analyzed the clinical data of 378 patients with EAS treated by BD from March 2011 to June 2021. The association between esophagogastric anastomotic rupture outcome and patient and stricture characteristics and treatment were analyzed by logistic regression.

RESULTS

BD was performed 552 times and technical success, 98.0%; overall clinical success, 97.8%; major adverse events, 1.3%; minor adverse events, 9.4%; mortality, 0.3%. Logistic regression showed that age (p = 0.080), sex (p = 0.256), interval from surgery to stricture development (p = 0.817), number of dilatations (p = 0.054), cause of stricture (p ≥ 0.168), and preoperative chemotherapy (p = 0.679) were not associated with anastomotic rupture. Balloon diameter (p < 0.001), preoperative radiotherapy (p = 0.003), and chemoradiotherapy (p = 0.021) were correlated with anastomotic rupture. All patients with type I and II ruptures resumed oral feeding without developing into type III rupture. Type III rupture occurred in six cases, who resumed oral feeding after 7-21 days of nasal feeding and liquid feeding. One patient died of massive bleeding after BD.

CONCLUSIONS

Symptomatic treatment for type I and II ruptures and transnasal decompression and jejunal nutrition tubes for type III rupture, are suggested pending rupture healing. Tumor recurrence, preoperative radiotherapy, and balloon diameter affected the anastomotic rupture outcome.

Comparison of the Efficacy and Safety of Endoscopic Incisional Therapy and Balloon Dilatation for Esophageal Anastomotic Stricture

BACKGROUND

Benign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy.

METHODS

Subjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus.

RESULTS

Twenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention.

CONCLUSIONS

EIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.

Diagnostic pitfalls: intramyocardial lymphoma metastasis mimics acute coronary syndrome in a diffuse large B cell lymphoma patient-case report

Background

Cardiac tumors are very uncommon compared to other cardiac diseases. Their clinical symptoms can vary from absent to non-specific. The most common symptoms are arrhythmias, blood flow obstruction due to valvular dysfunction, shortness of breath, systemic embolization, and accumulation of pericardial fluid. Hereby, we describe a very rare case of a diffuse large B cell lymphoma patient who presented with the symptoms and signs of acute coronary syndrome (ACS) but the patient’s complaints were caused by his intramyocardial lymphoma metastasis.

Case presentation

Forty-eight-year-old diffuse large B cell lymphoma patient was admitted to our emergency department with chest pain, effort dyspnea, and fever. The patient had normal blood pressure, blood oxygen saturation, sinus tachycardia, fever, crackles over the left lower lobe, novum incomplete right bundle branch block with Q waves and minor ST alterations, elevated C-reactive protein, high-sensitivity troponin-T, and d-dimer levels. Chest X-ray revealed consolidation on the left side and enlarged heart. Bed side transthoracic echocardiography showed inferior akinesis with pericardial fluid. Coronary angiography showed no occlusion or significant stenosis. Chest computed tomography demonstrated the progression of his lymphoma in the myocardium. He was admitted to the Department of Hematology for immediate chemotherapy and he reached complete metabolic remission, followed by allogeneic hematopoietic stem cell transplantation. Unfortunately, about 9 months later, he developed bone marrow deficiency consequently severe sepsis, septic shock, and multiple organ failure what he did not survive.

Conclusions

Our case demonstrates a very rare manifestation of a heart metastasis. ACS is an unusual symptom of cardiac tumors. But our patient’s intramyocardial lymphoma in the right atrium and ventricle externally compressed the right coronary artery and damaged the heart tissue, causing the patient’s symptoms which imitated ACS. Fortunately, the quick diagnostics and immediate aggressive chemotherapy provided the patient’s remission and suitability to further treatment.

Radiation-induced esophageal strictures treated with fluoroscopic balloon dilation: clinical outcomes and factors influencing recurrence in 62 patients

Background Balloon dilation is safe and effective for the treatment of radiation-induced esophageal stricture (RIES), with favorable short-term and mid-term outcomes; however, few reports of long-term outcomes exist. Few studies have evaluated factors associated with recurrence after balloon dilation. Purpose To evaluate the long-term outcome of balloon dilation in patients with RIES and to identify factors associated with stricture recurrence. Material and Methods The medical records of 62 consecutive patients who had undergone fluoroscopic balloon dilation for RIES at our institution between December 1998 and June 2016 were reviewed. Results One hundred and twenty balloon dilation sessions were performed in 62 patients (mean = 1.9 sessions per patient). Clinical success was achieved in 53 (86%) patients after single (n = 37) or multiple (n = 16) dilation sessions. Complications occurred in 27% of the dilation sessions. The primary patency rates at one, two, three, and five years were 60%, 56%, 52%, and 52%, respectively. Secondary patency rates at one, two, three, and five years were 87%, 85%, 85%, and 80%, respectively. Multivariate logistic regression analysis identified an interval from radiation therapy (RT) to stricture of ≥6 months (hazard ratio [HR] = 0.205; P < 0.001), strictures located at the cervical esophagus (HR = 5.846; P < 0.001), and stricture length of ≥2 cm (HR = 2.923; P = 0.006) as significant predictors of recurrence. Conclusion Despite the high incidence of ruptures and recurrences, fluoroscopic balloon dilation is valuable as an initial therapeutic option for patients with RIES.

Fluoroscopic removal of retrievable self-expandable metal stents in patients with malignant oesophageal strictures: Experience with a non-endoscopic removal system

OBJECTIVES

To evaluate clinical outcomes of fluoroscopic removal of retrievable self-expandable metal stents (SEMSs) for malignant oesophageal strictures, to compare clinical outcomes of three different removal techniques, and to identify predictive factors of successful removal by the standard technique (primary technical success).

METHODS

A total of 137 stents were removed from 128 patients with malignant oesophageal strictures. Primary overall technical success and removal-related complications were evaluated. Logistic regression models were constructed to identify predictive factors of primary technical success.

RESULTS

Primary technical success rate was 78.8 % (108/137). Complications occurred in six (4.4 %) cases. Stent location in the upper oesophagus (P=0.004), stricture length over 8 cm (P=0.030), and proximal granulation tissue (P<0.001) were negative predictive factors of primary technical success. If granulation tissue was present at the proximal end, eversion technique was more frequently required (P=0.002).

CONCLUSIONS

Fluoroscopic removal of retrievable SEMSs for malignant oesophageal strictures using three different removal techniques appeared to be safe and easy. The standard technique is safe and effective in the majority of patients. The presence of proximal granulation tissue, stent location in the upper oesophagus, and stricture length over 8 cm were negative predictive factors for primary technical success by standard extraction and may require a modified removal technique.

KEY POINTS

• Fluoroscopic retrievable SEMS removal is safe and effective. • Standard removal technique by traction is effective in the majority of patients. • Three negative predictive factors of primary technical success were identified. • Caution should be exercised during the removal in those situations. • Eversion technique is effective in cases of proximal granulation tissue.

Incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation in children with benign strictures

OBJECTIVES

The purpose of this study is to investigate the incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation (FBD) in children with benign oesophageal strictures.

METHODS

Sixty-two children with benign oesophageal strictures underwent FBDs. Oesophageal rupture was categorized as intramural (type 1), transmural (type 2), or transmural with free leakage (type 3). The possible risk factors for oesophageal ruptures were analyzed.

RESULTS

One hundred and twenty-nine FBDs were performed in these patients. The oesophageal rupture rate was 17.1 % (22/129). The majority (21/22) of ruptures were type 1 and type 2, both were treated conservatively. Only one patient had a type 3 rupture and underwent oesophagoesophagostomy. The patient gender, age, and the length and cause of the stricture showed no significant effect on the rupture (P > 0.05). However, for the patients ≤2 years old, the initial balloon with a diameter ≥10 mm showed a higher oesophageal rupture rate than those <10 mm during the first session (P = 0.03).

CONCLUSIONS

Although the oesophageal rupture rate in children was 17.1 %, the type 3 rupture rate was 0.8 %, which usually requires aggressive treatment. For children ≤2 years old, the initial balloon diameter should be <10 mm in the first session for decreasing the risk of oesophageal rupture.

KEY POINTS

• The oesophageal rupture rate following balloon dilatation in children was 17.1 %. • The incidence of transmural rupture with free leakage is very low. • Only transmural rupture with free leakage needs aggressive treatment. • For children ≤2 years, the initial balloon diameter should be <10 mm.

Benign anastomotic strictures after esophagectomy: long-term effectiveness of balloon dilation and factors affecting recurrence in 155 patients

OBJECTIVE

The purpose of this article is to retrospectively evaluate the long-term clinical results of balloon dilation in the treatment of benign anastomotic strictures after esophagectomy and to identify factors associated with stricture recurrence.

MATERIALS AND METHODS

From January 1996 to June 2011, a total of 309 sessions of balloon dilation were performed in 155 patients with benign anastomotic strictures after esophagectomy. Long-term clinical effectiveness was assessed using the following variables: technical and clinical success, complications, and patency rates. Factors independently related to recurrence were evaluated with the Cox model. Tested variables were age, sex, operation type, postoperative anastomotic leakage, balloon size, length of stricture, time to postoperative stricture development, complications, and neoadjuvant chemoradiotherapy.

RESULTS

The mean follow-up period was 37 months (range, 1-159 months). Overall clinical success was achieved in 153 patients (99%) after a single (n = 78) or multiple (n = 75) balloon dilations. During follow-up, recurrence of the stricture requiring repeated dilation was seen in 77 of 155 patients (50%). Esophageal rupture (mostly intramural rupture) occurred in 22 of 155 patients (14%) and 34 of 309 balloon dilations (11%). In multivariate analysis, early development of stricture within 10 weeks after surgery (p = 0.002) and McKeown esophagectomy (p = 0.002) were independently related to recurrence after initial balloon dilation.

CONCLUSION

Balloon dilation under fluoroscopic guidance has encouraging long-term results in the treatment of benign anastomotic strictures after esophagectomy. However, recurrence after balloon dilation was common, with McKeown esophagectomy and development of stricture within 10 weeks after surgery associated with recurrent strictures.

Fluoroscopically guided balloon dilation of benign esophageal strictures: incidence of esophageal rupture and its management in 589 patients

OBJECTIVE

The purpose of this article is to investigate the incidence and management of esophageal rupture caused by balloon dilation in patients with benign esophageal strictures.

MATERIALS AND METHODS

Fluoroscopically guided esophageal balloon dilation was performed on 589 patients with benign esophageal strictures during an 18-year period. The strictures had a range of causes: postoperative anastomotic stricture, corrosive stricture, postradiation stricture, esophageal achalasia, esophageal reflux, congenital stricture, esophageal web, esophageal ulcer, medication fibrosis, chronic inflammation, and posttraumatic stricture (in descending order of frequency). Esophageal rupture was assigned to one of three categories: type 1 was intramural, type 2 was transmural with a contained leak, and type 3 was transmural with an uncontained mediastinal leakage.

RESULTS

A total of 1421 procedures were performed in 589 patients, with each patient undergoing 1-29 procedures. The technical success rate was 99.8%, and the clinical success rate was 91.7%. Patients with corrosive stricture underwent the highest number of procedures (mean, 4.38 procedures). The incidence of esophageal rupture was 14.7%. All esophageal ruptures were detected immediately after the procedure. Most ruptures (98.6%) were types 1 and 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. One of the type 3 ruptures was successfully treated with a retrievable covered stent. Two patients with type 3 ruptures (0.96% of ruptures) underwent surgery and were successfully treated. The rupture rate was not statistically related to the diameter of balloon used.

CONCLUSION

The incidence of esophageal rupture after fluoroscopically guided esophageal balloon dilation was 14.7%. Almost all ruptures were type 1 or 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. There was no procedure-related mortality in any patient. Therefore, in spite of the high incidence of ruptures, fluoroscopically guided balloon dilation is a safe procedure, particularly if a rupture is identified early and managed appropriately.

Benign strictures of the esophagus and gastric outlet: interventional management

Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy.

Oesophageal strictures caused by the ingestion of corrosive agents: effectiveness of balloon dilatation in children

AIM

To evaluate the safety and clinical effectiveness of balloon dilatation in children for oesophageal strictures caused by the ingestion of corrosive agents.

MATERIALS AND METHODS

The study comprised 11 children (median age 6 years; range 1-14 years) with oesophageal strictures caused by corrosive agents, who underwent a total of 36 balloon dilatation sessions. The technical and clinical success, recurrence of dysphagia, complications, and primary and secondary patency rates were retrospectively evaluated.

RESULTS

Technical success was achieved in 91% of patients and in 97% of balloon dilatation sessions. Clinical success (defined as improved food intake and reduced dysphagia within 1 month of the first balloon dilatation session) was achieved in 64% of patients (7/11). During the mean 35-month follow-up period (range 1-89 months), 10 (91%) patients experienced recurrence. Oesophageal rupture (types 1 or 2) occurred in 45% of patients and in 31% of balloon dilatation sessions. Primary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 36, 27, 14, 14, 14, and 14%, respectively. Secondary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 82, 82, 82, 56, 42, and 42%, respectively. The secondary patency rate was higher than the primary patency rate (p<0.05).

CONCLUSION

The present study examined oesophageal balloon dilatation for paediatric oesophageal strictures caused by the ingestion of corrosive agents. Although the technical success rate was high and there were no deaths, the clinical success rate was low owing to a high recurrence rate. However, repeated balloon dilatations resulted in an acceptable secondary patency rate.

Esophageal achalasia: comparison of fluoroscopically-guided double vs. endoscopically-guided single balloon dilation

PURPOSE

To compare the long-term clinical effectiveness of fluoroscopically guided double and endoscopically guided single balloon dilations in esophageal achalasia.

MATERIALS AND METHODS

Thirty-two fluoroscopically guided balloon dilations were performed in 21 patients (group A) and 48 endoscopically guided balloon dilations were performed in 37 patients (group B). The double balloon dilation technique (10 + 20-mm, 15 + 20-mm or 20 + 20-mm in diameter), with preceding single balloon dilation (10, 15, or 20-mm in diameter), was used in group A, whereas the single balloon dilation technique (30, 35, or 40-mm in diameter) with gradually increased internal pressure was used in group B. Technical success, clinical success, complications, and primary/secondary patency rates were compared between the two groups.

RESULTS

All procedures were technically successful without esophageal perforation. Clinical success was achieved in 97% (31/32) and 92% (44/48) of balloon dilations in groups A and B, respectively. The symptomatic improvement in dysphagia was significantly higher in group A than in group B. Incidence of complications was the same (18.8%) in both groups. Group A showed significantly longer primary and secondary patency periods than did group B (P < 0.05).

CONCLUSION

Fluoroscopically guided double balloon dilation has greater long-term effectiveness than endoscopically guided single balloon dilation in the treatment of esophageal achalasia.

Corrosive esophageal strictures: long-term effectiveness of balloon dilation in 117 patients

PURPOSE

To retrospectively evaluate the long-term results of balloon dilation in the treatment of corrosive esophageal strictures and to identify prognostic factors associated with clinical outcome.

MATERIALS AND METHODS

From January 1987 to June 2006, balloon dilation was undertaken in 117 patients with corrosive esophageal strictures. Information on recurrence and complications was obtained. Recurrence rates and factors predicting recurrences were evaluated with Kaplan-Meier survival analysis and Cox multivariate analysis. Tested variables were age, sex, corrosive agent, stricture length, stricture number, severity of stricture as judged by the resistance to dilation, and stage (early chronic [3 weeks to 6 months] vs late chronic [>6 months]).

RESULTS

The mean follow-up period was 51 months (range, 1-174 months). Thirty patients (26%) had no recurrence after initial balloon dilation. Twenty-three patients (20%) experienced no recurrence after one or two additional balloon dilation procedures. Forty-five of 117 patients (38%) experienced esophageal rupture (mostly intramural rupture). Early chronic stage (P=.003) and resistance to balloon dilation in the late chronic stage (P=.034) were significantly associated with recurrence after balloon dilation.

CONCLUSIONS

Balloon dilation is associated with minimal complications and is valuable as an initial therapy in patients with corrosive esophageal stricture. However, the recurrence rate after balloon dilation is rather high, with early chronic stage and resistance to dilation in the late chronic stage associated with poor clinical outcome. An algorithm combining balloon dilation with temporary stent placement is proposed for the subsets of patients prone to stricture recurrence.

Fluoroscopically Guided Balloon Dilation of Anastomotic Strictures After Total Gastrectomy: Long-Term Results

OBJECTIVE

The purpose of this study was to evaluate the radiologic and clinical effectiveness and long-term results of fluoroscopically guided balloon dilation of anastomotic strictures after total gastrectomy.

CONCLUSION

Fluoroscopically guided balloon dilation is effective and safe and has encouraging long-term results in the management of benign anastomotic strictures after total gastrectomy.

Balloon Dilation of Anastomotic Strictures Secondary to Surgical Repair of Esophageal Atresia in a Pediatric Population: Long-term Results

PURPOSE

To evaluate the clinical effectiveness and long-term results of balloon dilation treatment for strictures secondary to surgical repair of esophageal atresia (EA) in 29 children.

MATERIALS AND METHODS

The study involved 29 children aged 1-60 months with strictures of greater than 50% at anastomotic sites. The interval between surgical repair and balloon dilation ranged from 1 to 36 months (mean, 6.4 months). All procedures were performed under general anesthesia with use of fluoroscopic guidance. Balloon catheter diameters ranged from 8 mm to 16 mm. Outcome parameters measured included the number of dilations, procedural success rates, primary and secondary clinical success rates, and complications such as esophageal perforation. Primary clinical success was defined as an absence of dysphagia for at least 1 year and weight gain appropriate to the patient's age after initial balloon dilation. Secondary clinical success was defined as an absence of dysphagia for at least 1 year after the final dilation and weight gain appropriate to the patient's age after one or more balloon dilation sessions.

RESULTS

A total of 44 balloon dilation sessions were performed, with patients undergoing one to five dilation procedures (mean, 1.6 per patient; median, 1 per patient). Primary and secondary clinical success rates were 59% (17 of 29) and 93% (27 of 29), respectively. During the mean follow-up period of 3.1 years (range, 1-12 y), all 27 children with clinical success showed no recurring symptoms. In terms of complications, transmural perforation occurred in three children (10%), two of whom received conservative management and one of whom underwent surgery for combined esophageal rupture and esophagotracheal fistula. No mortalities occurred.

CONCLUSION

Balloon dilation is a safe and effective procedure with excellent long-term results for the treatment of anastomotic strictures secondary to surgical repair of EA in a pediatric population.

Salvage of a massive esophago-tracheal fistula resulting from a stenting treatment

We report the successful surgical resolution of a case of massive esophago-tracheal fistula (ETF) caused by a stenting treatment for stricture of an esophago-gastric anastomosis. A 54-year-old man was admitted to our hospital due to serious pneumonia secondary to ETF. He had previously received esophagectomy and post-operative chemo-radiation therapy for esophageal cancer, followed by stenting treatments for a benign stricture of the esophago-gastric anastomosis. For surgical treatment of the resulting ETF, serial operations were required. The first operation, performed under percutaneous cardiopulmonary support, included removal of the stents followed by tracheotomy, were with the coverage of the tracheal defect achieved using both major pectoral muscle flaps. A salivary fistula was also generated and an enteral nutrition tube was placed. Six months after the first operation, a pedicled ileocolic interposition was performed in order to effect reconstruction of the digestive tube, with an additional microvascular anastomosis of the ileocolic and internal thoracic artery and vein. After the second operation, the patient's ability to ingest food was restored, and he was discharged from the hospital. Thus, ETF was successfully treated by successive surgical operations with delicate intra- and post-operative respiratory management.

Deep tracheal laceration after balloon dilation for benign tracheobronchial stenosis: case reports of two patients

We report two cases of deep tracheal laceration in female patients after balloon dilation for benign tracheobronchial stenosis. Immediate post-procedure bronchoscopy and CT including 3D reconstructions showed deep lacerations in the posterior tracheal wall. Clinically, the patients' dyspnoea subsided and there has been no recurrence during follow-up after balloon dilation. On the follow-up 3D-reconstructed CT scans obtained 2 months and 8 months following balloon dilation, respectively, the lacerations had healed completely and there was considerable improvement in lumen size.

Fluoroscopically guided balloon dilation for patients with esophageal stricture after radiation treatment

PURPOSE

To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with esophageal stricture after radiation therapy (RT).

MATERIALS AND METHODS

From April 1993 through December 2004, fluoroscopically guided balloon dilation was performed in 15 patients with esophageal strictures secondary to previous RT. Technical success, clinical success, recurrence of dysphagia, primary and secondary patency rates, and complications related to the procedure were retrospectively evaluated.

RESULTS

Twenty-five balloon dilations were performed in 15 patients, with a mean of 1.7 dilations per patient (range, 1-5). Technical success was achieved in all procedures. One patient was immediately lost to follow-up and another underwent elective esophageal surgery 13 days after the procedure. Of the remaining 13 patients, clinical success was achieved 11 (85%). Two of 13 patients exhibited recurrence of dysphagia before 1 month after balloon dilation. Among the 11 patients in whom clinical success was achieved, seven exhibited maintained initial improvement of dysphagia until their last follow-up (mean, 174 days) and four exhibited recurrence of dysphagia after the first balloon dilation. Dysphagia recurred 2-128 days (mean, 67.2 d) after the first balloon dilation in six of the 13 patients (46%), who underwent further balloon dilation and/or stent placement. The primary and secondary patency rates at 1, 3, and 6 months were 86%, 68%, and 47% and 100%, 92%, and 62%, respectively. There were no major complications. Type 1 and 2 esophageal ruptures occurred after 12 dilations in nine patients; they were treated conservatively.

CONCLUSION

Fluoroscopically guided balloon dilation for esophageal stricture after RT can be safe and effective. However, the high rate of recurrent dysphagia requires repeated dilations.

Benign duodenal strictures: treatment by means of fluoroscopically guided balloon dilation

Fluoroscopically guided balloon (15 or 20 mm in diameter) dilation was performed on eight patients with benign duodenal strictures caused by peptic ulcers (n = 6), Crohn's disease (n = 1), and postoperative adhesion (n = 1). The procedure was technically and clinically successful without complications in seven of the eight patients (88%). Duodenal perforation occurred immediately after 20-mm-diameter balloon dilation in one patient who underwent emergency surgery. During the mean follow-up of 30 months (range, 2-103 months), there was recurrence in two of the seven patients (29%) who then underwent surgery. The other five patients (71%) showed good results with no recurrence.

Colorectal Anastomotic Strictures: Treatment by Fluoroscopic Double Balloon Dilation

PURPOSE

To evaluate the therapeutic efficacy and complications of fluoroscopically guided double balloon dilation for treatment of colorectal anastomotic strictures.

MATERIALS AND METHODS

Under fluoroscopic guidance, 17 patients with colorectal anastomotic strictures underwent transanal double balloon dilation. Thirteen of 17 strictures were the consequence of surgery for malignant disease and the other four were secondary to surgery for benign disease. Sixteen of 17 patients had difficult or frequent defecation caused by partial obstruction. In the remaining one asymptomatic patient, the stricture was detected by endoscopy and barium enema after total proctocolectomy and a temporary ileostomy for ulcerative colitis. The therapeutic efficacy and complications were evaluated during the follow-up.

RESULTS

Seventeen patients underwent double balloon dilation in a single session. The diameter of the first balloon was 20 mm and the second balloon's diameter was 10, 15, or 20 mm. Technical success was achieved in all 17 patients. After balloon dilation, complete (n = 12, 71%) or incomplete (n = 5, 29%) improvement of symptoms was achieved in all patients. Major complications such as perforation or severe hemorrhage did not occur. During the mean follow-up period of 23 months (range, 1-62 months), one patient (6%) developed a recurrent stricture and required a second session of double balloon dilation 6 months after initial balloon dilation.

CONCLUSION

Fluoroscopically guided double balloon dilation is an effective and safe method for the treatment of colorectal anastomotic strictures.

Temporary partially-covered metal stent insertion in benign esophageal stricture

AIM: To study the therapeutic efficacy of temporary partially-covered metal stent insertion on benign esophageal stricture.

METHODS: Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores.

RESULTS: Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20 ± 0.63 (mean ± SD) and 0.68 ± 0.31 before and after stent insertion, and 0.86 ± 0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37 ± 1.23 mm and 25.77 ± 3.89 mm before and after stent insertion, and 16.15 ± 2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26 ± 12.75 months). The complications were chest pain (n = 37) after stent insertion, and bleeding (n = 12) and reflux (n = 13) after stent removal.

CONCLUSION: Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.

Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia

The purpose of this study was to evaluate the efficiency and safety of oesophageal balloon dilatation in strictures secondary to surgical treatment of oesophageal atresia in 25 children. Patients comprised 15 males and 10 females, aged 1-36 months. Median age was 4 months (interquartile range (IQR)=19). The strictures were more than 50% of oesophageal lumen and the delay from surgical treatment to balloon dilatation varied from 1 month to 36 months. Associated gastroesophageal reflux was noted in 15 patients. All procedures were performed under sedation using fluoroscopic guidance. Balloons of increasing diameter, 4-20 mm were used. Water soluble contrast swallow was performed after each dilatation session. A total of 115 balloon dilatation sessions were performed with a range of 1-14 procedures per patient (median 4 dilatations, IQR=4.5). Dilatation relieved the stricture in all patients over a follow-up period varying from 4 months to 33 months. The best results were noted in children under 6 months, who needed two or few dilatation sessions, with relative risk (RR) of 0.52 and 95% confidence interval of 0.29-0.92. The presence of associated gastroesophageal reflux indicated a high risk (RR of 12, p<0.001) for undergoing more than two balloon dilatation sessions. The only serious complications observed were two cases of oesophageal perforation, which were treated conservatively. Fluoroscopically guided balloon dilatation is a safe and effective treatment in the management of strictures secondary to surgical repair of oesophageal atresia, especially when started early (within 6 months of surgery) and not associated with gastroesophageal reflux.