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Kim Y, Na HK, Ahn JY, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Association of local steroid injection as a risk factor for electrocoagulation syndrome after esophageal endoscopic submucosal dissection. Surg Endosc 2024; 38:3858-3865. [PMID: 38831214 DOI: 10.1007/s00464-024-10927-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Postendoscopic submucosal dissection electrocoagulation syndrome (PEECS) is commonly observed after performing endoscopic submucosal dissection (ESD) for esophageal neoplasia. However, data on the incidence and risk factors for PEECS in the esophagus are lacking due to an unclear definition of PEECS and varied clinical settings. Therefore, we aimed to determine the risk factors for PEECS in patients undergoing ESD for esophageal neoplasia. METHODS We retrospectively reviewed data of relevant clinical and endoscopy-specific parameters from 202 consecutive patients with esophageal neoplasias (139 carcinomas and 63 dysplasias) who underwent ESD under general anesthesia. Esophageal PEECS was defined by satisfying at least two of the following criteria: fever ≥ 37.8 °C, leukocytosis ≥ 10,800/mm3, and localized chest pain ≥ 5/10 points as assessed on a numeric rating scale within 24 h after ESD. Significant factors associated with PEECS were determined by regression analysis. RESULTS PEECS was recorded in 98 of 202 (48.5%) patients. Patients with PEECS exhibited a larger tumor size (25.0 vs. 17.0 mm, P = 0.002), longer procedure (40.0 vs. 29.5 min, P = 0.021) and hemostasis times (5.0 vs. 3.5 min, P = 0.004), required greater submucosal injection volume (60.0 mL vs. 50.0 mL, P = 0.030), and had a lower rate of local steroid injection (4.1% vs. 12.5%, P = 0.029) than those without PEECS. Multivariate regression analysis revealed tumor size ≥ 17 mm (P = 0.047), procedure time ≥ 33 min (P = 0.027), and hemostasis time ≥ 5 min (P = 0.007) as risk factors for PEECS. In addition, local steroid injection was a significant negatively associated factor (P = 0.001). CONCLUSIONS Patients with a large tumor, prolonged procedure and hemostasis times are at a high risk of PEECS occurrence. Further, local steroid injection is a negatively associated factor.
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Affiliation(s)
- Yuri Kim
- Division of Gastroenterology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Jimoh Z, Jogiat U, Hajjar A, Verhoeff K, Turner S, Wong C, Kung JY, Bédard ELR. Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis. Surg Endosc 2024; 38:2995-3003. [PMID: 38649492 DOI: 10.1007/s00464-024-10817-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/22/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. METHODS A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. RESULTS A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. CONCLUSION Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.
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Affiliation(s)
| | - Uzair Jogiat
- Division of Thoracic Surgery, Univesity of Alberta, Edmonton, AB, Canada.
- Division of General Surgery, Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom, 2G2 Walter C. Mackenzie Health Sciences Center, 8440-112 St NW, Edmonton, AB, T6G2B7, Canada.
| | - Alex Hajjar
- Division of Thoracic Surgery, Univesity of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Division of Thoracic Surgery, Univesity of Alberta, Edmonton, AB, Canada
| | - Simon Turner
- Division of Thoracic Surgery, Univesity of Alberta, Edmonton, AB, Canada
| | - Clarence Wong
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Janice Y Kung
- Geoffrey & Robyn Sperber Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Eric L R Bédard
- Division of Thoracic Surgery, Univesity of Alberta, Edmonton, AB, Canada
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Norton BC, Papaefthymiou A, Aslam N, Telese A, Murray C, Murino A, Johnson G, Haidry R. The endoscopic management of oesophageal strictures. Best Pract Res Clin Gastroenterol 2024; 69:101899. [PMID: 38749578 DOI: 10.1016/j.bpg.2024.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/04/2024] [Accepted: 02/25/2024] [Indexed: 05/26/2024]
Abstract
An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.
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Affiliation(s)
- Benjamin Charles Norton
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Centre for Obesity Research, Department of Medicine, University College London, Rayne Institute, 5 University St, London, WC1E 6JF, UK.
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Nasar Aslam
- Department of Gastroenterology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Andrea Telese
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Division of Surgery and Interventional Science, University College London, Royal Free Hospital, 10 Pond Street, London, NW3 2PS, UK
| | - Charles Murray
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Alberto Murino
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Gavin Johnson
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Rehan Haidry
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
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Jessamy K, Jessamy A, Anozie O. Endoscopic Glucocorticoid Injection for the Treatment of a Refractory Benign Esophageal Stenosis in a Patient With Plummer-Vinson Syndrome. Cureus 2023; 15:e41896. [PMID: 37457608 PMCID: PMC10349547 DOI: 10.7759/cureus.41896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
Plummer-Vinson syndrome (PVS) or Paterson-Brown-Kelly syndrome is a rare clinical condition characterized by the triad of esophageal webs/stenoses, iron-deficiency anemia, and progressively worsening dysphagia. It occurs mostly in Caucasian women in the fourth to seventh decades, particularly in northern countries. Esophageal webs and stenoses can be encountered during endoscopic evaluation for the patient's complaint of dysphagia. Esophageal stenoses are characterized as simple or complex. A stenosis should be considered refractory once the patient has undergone several sequential dilatations within short intervals, optimized treatment for potential underlying causes (eosinophilic esophagitis or acid reflux), and after neuromuscular causes have been excluded. Glucocorticoid injection into a stenosis during an endoscopic dilation session has been proven to be beneficial as the initial treatment modality of refractory nonmalignant esophageal stenoses. We present a case of a 39-year-old woman with refractory esophageal stenosis in the setting of PVS which was successfully treated with serial endoscopic glucocorticoid injections while she received oral iron supplementation. To our knowledge, there are no previous cases of esophageal stenoses associated with PVS in the literature requiring endoscopic glucocorticoid injection for successful resolution.
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Affiliation(s)
- Kegan Jessamy
- Gastroenterology, Tidelands Health Gastroenterology, Georgetown, USA
| | - Amy Jessamy
- Medicine, The University of the West Indies, St. Augustine, TTO
| | - Obiajulu Anozie
- Critical Care Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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Sarma MS, Tripathi PR, Arora S. Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas. World J Clin Pediatr 2021; 10:124-136. [PMID: 34868889 PMCID: PMC8603639 DOI: 10.5409/wjcp.v10.i6.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/30/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.
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Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Parijat Ram Tripathi
- Department of Pediatric Gastroenterology, Ankura Hospsital for Women and Children, Hyderabad 500072, Telangana, India
| | - Sachin Arora
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Gankov VA, Andreasyan AR, Maslikova SA, Bagdasaryan GI, Shestakov DY. THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-2-14-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.
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7
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Infectious Abscess as Complication of Steroid Injection With Dilation of Refractory Upper Gastrointestinal Strictures. ACG Case Rep J 2021; 8:e00619. [PMID: 34250174 PMCID: PMC8248511 DOI: 10.14309/crj.0000000000000619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/30/2021] [Indexed: 11/21/2022] Open
Abstract
Benign, refractory upper gastrointestinal strictures can be challenging to treat. Dilation combined with intralesional steroid injection is part of treatment algorithms. This intervention is typically well-tolerated, and few complications of this technique have been reported in the literature. We report 2 patients with infectious abscesses, 1 involving the neck and 1 involving the pylorus, as a complication of steroid injection and dilation of refractory strictures.
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8
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Endoscopic Management of Refractory Benign Esophageal Strictures. Dysphagia 2021; 36:504-516. [PMID: 33710389 DOI: 10.1007/s00455-021-10270-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.
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Boregowda U, Goyal H, Mann R, Gajendran M, Patel S, Echavarria J, Sayana H, Saligram S. Endoscopic management of benign recalcitrant esophageal strictures. Ann Gastroenterol 2021; 34:287-299. [PMID: 33948052 PMCID: PMC8079876 DOI: 10.20524/aog.2021.0585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022] Open
Abstract
Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.
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Affiliation(s)
- Umesha Boregowda
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY (Umesha Boregowda)
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduation Medical Center, Scranton, PA (Hemant Goyal)
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA (Rupinder Mann)
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX (Mahesh Gajendran)
| | - Sandeep Patel
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Juan Echavarria
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Hari Sayana
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Shreyas Saligram
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
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10
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van Hal ARL, Pulvirenti R, den Hartog FPJ, Vlot J. The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review. Front Pediatr 2021; 9:825030. [PMID: 35165653 PMCID: PMC8837747 DOI: 10.3389/fped.2021.825030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures. METHODS A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention. RESULTS The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3). CONCLUSION The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI. SYSTEMATIC REVIEW REGISTRATION PROSPERO, identifier: CRD42021281584.
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Affiliation(s)
- Annefleur R L van Hal
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
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11
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Intralesional steroids and endoscopic dilation for anastomotic strictures after esophagectomy: systematic review and meta-analysis. Endoscopy 2020; 52:721-726. [PMID: 32450581 DOI: 10.1055/a-1172-5975] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-esophagectomy anastomotic strictures are difficult to treat. The impact of adding local steroid injection to endoscopic dilation for the treatment of post-esophagectomy anastomotic strictures is unclear. We conducted a systematic review and meta-analysis to assess the efficacy of performing steroid injection in addition to dilation. METHODS A search was conducted in MEDLINE, Cochrane Library, EMBASE, and Web of Science from inception to January 2019. Randomized controlled trials (RCTs) comparing the efficacy of endoscopic dilation plus either local steroid injection (steroid group) or saline injection (placebo group) were included in the analysis. RESULTS Three RCTs were eligible for the final analysis: 72 patients (mean age 61.3 years, 74 % male) in the steroid group and 72 patients (mean age 59.6 years, 71 % male) in the placebo group. The mean number of dilations required to resolve the stricture was significantly lower in the steroid group compared with the placebo group, with a mean weighted difference of -1.62 (95 % confidence interval [CI] -2.73 to -0.50; P = 0.004). After 6 months of follow-up, there was a trend toward more patients in the steroid group remaining dysphagia free compared with the placebo group, with a pooled odds ratio of 2.36 (95 %CI 0.94 to 5.91; P = 0.07, I2 = 24 %). CONCLUSION This meta-analysis showed that the addition of local steroid injection at the time of dilation for benign anastomotic strictures led to a significant decrease in the number of procedures required to resolve the stricture and may well reduce dysphagia symptoms during follow-up.
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12
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Intralesional Steroid Injection Therapy for Esophageal Anastomotic Stricture Following Esophageal Atresia Repair. J Pediatr Gastroenterol Nutr 2020; 70:462-467. [PMID: 31764412 DOI: 10.1097/mpg.0000000000002562] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The role of intralesional steroid injection (ISI) in the treatment of anastomotic stricture in patients with esophageal atresia remains unclear. The aim of this study was to evaluate the efficacy and safety of ISI. METHODS A total of 158 patients with esophageal atresia with at least 1 ISI for the treatment of esophageal anastomotic stricture between 2010 and 2017 were identified. The change in stricture diameter (ΔD) was compared between procedures with dilation alone (ISI-) and dilation with steroid injection (ISI+). RESULTS A total of 1055 balloon dilations were performed (452 ISI+). The median ΔD was significantly greater in the ISI+ group: 1 mm (interquartile range [IQR] 0, 3) versus 0 mm (IQR -1, 1.5) (P < 0.0001). The ISI+ group had greater percentage of improved diameter (P < 0.0001) and lesser percentages of unchanged and decreased diameters at subsequent endoscopy (P = 0.0009, P = 0.003). Multivariable logistic regression confirmed the significance of ISI on increasing the likelihood of improved stricture diameter with an adjusted odds ratio of 3.24 (95% confidence interval: 2.15-4.88) (P < 0.001). The ΔD for the first 3 ISI+ procedures was greater than the ΔD for subsequent ISI+ procedures: 1 mm (IQR 0, 3) versus 0.5 mm (IQR-1.25, 2) (P = 0.001). There was no difference in perforation incidence between ISI+ and ISI- groups (P = 0.82). CONCLUSIONS ISI with dilation was well tolerated and improved anastomotic stricture diameter more than dilation alone. The benefit of ISI over dilation alone was limited to the first 3 ISI procedures.
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13
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Everett SM. Endoscopic management of refractory benign oesophageal strictures. Ther Adv Gastrointest Endosc 2019; 12:2631774519862134. [PMID: 31460518 PMCID: PMC6702770 DOI: 10.1177/2631774519862134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/16/2019] [Indexed: 12/17/2022] Open
Abstract
Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.
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Affiliation(s)
- Simon M Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
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14
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Yang K, Cao J, Yuan TW, Zhu YQ, Zhou B, Cheng YS. Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model. World J Gastroenterol 2019; 25:3207-3217. [PMID: 31333312 PMCID: PMC6626718 DOI: 10.3748/wjg.v25.i25.3207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures (BES). Magnesium alloy stents are a good candidate because of biological safety, but show a poor corrosion resistance and a quick loss of mechanical support in vivo.
AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent.
METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance (stent group). The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models (control group). Esophagography was performed at 1, 2, and 3 weeks. Four, six, and five rabbits in the stent group and two rabbits in the control groups were euthanized, respectively, at each time point for histological examination.
RESULTS All stent insertions were well tolerated. The esophageal diameters at immediately, 1, 2 and 3 wk were 9.8 ± 0.3 mm, 9.7 ± 0.7 mm, 9.4 ± 0.8 mm, and 9.2 ± 0.5 mm, respectively (vs 4.9 ± 0.3 mm before stent insertion; P < 0.05). Magnesium stents migrated in eight rabbits [one at 1 wk (1/15), three at 2 wk (3/11), and four at 3 wk (4/5)]. Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was found significantly thinner in the stent group than in the control group (P < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits (P > 0.05).
CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction. Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.
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Affiliation(s)
- Kai Yang
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Jun Cao
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Tian-Wen Yuan
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Yue-Qi Zhu
- Department of Radiological Intervention, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
| | - Bi Zhou
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Ying-Sheng Cheng
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
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15
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Burr NE, Everett SM. Management of benign oesophageal strictures. Frontline Gastroenterol 2019; 10:177-181. [PMID: 31205660 PMCID: PMC6540277 DOI: 10.1136/flgastro-2018-101075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Benign oesophageal strictures are an important gastrointestinal condition that can cause substantial morbidity. There are many different aetiologies and each case needs careful evaluation and individualised treatment. Management usually involves targeting therapy to the underlying cause, but oesophageal dilatation is an important part of the algorithm. The recent British Society of Gastroenterology guidelines provide advice on the use of dilatation for benign strictures and cover patient preparation, the dilatation procedure and disease-specific considerations. This article provides a summary of the key messages from the guidelines and applies them to routine clinical practice. It also includes practical advice on the clinical assessment, investigation and management of benign oesophageal strictures and gives an approach to the management of refractory strictures. Areas where evidence is sparse and further research is needed are highlighted.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Simon M Everett
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
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