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

Trans-Balloon Visualisation During Dilatation (TBVD) of Oesophageal Strictures: a Novel Innovation

BACKGROUND

Hydrostatic balloon dilatation of upper gastrointestinal strictures is associated with a risk of perforation that varies with the underlying pathology and with the technique employed. We present a technique of trans-balloon visualisation of the stricture during dilatation (TBVD) that allows direct 'real-time' observation of the effect of dilatation on the stricture, facilitating early recognition of mucosal abruption, thereby reducing the perforation rate.

PATIENTS AND METHODS

We retrospectively analysed 100 consecutive patients, undergoing balloon dilatation of oesophageal strictures between 1st of January 2011 and 1st of July 2014.

RESULTS

One hundred patients underwent 186 dilatations, with 34 having multiple procedures (mean 1.86). All had oesophageal strictures (mean diameter 8.49 mm, range 5-11 mm) and most underwent dilatation up to a maximum of 17 mm (mean 14.7 mm). Fifty-six percent were male and the average age was 62.5 years (17-89 years). Only one patient (0.5% of all procedures) had a full-thickness perforation requiring intervention while just one further patient had a deep mucosal tear that did not require intervention.

CONCLUSIONS

TBVD is a safe technique with a short learning curve and is one of the important factors that allow potentially difficult dilatations to be performed safely with an exceptionally low rate of adverse events of less than 1%.

Successful Use of Esophageal Stent Placement to Treat a Postoperative Esophageal Stricture in a Toddler

Esophageal atresia (EA) is the most common type of gastrointestinal atresia. The most common variant (type C) consists of a blind esophageal pouch with a fistula between the trachea and the distal esophagus. Surgical repair can be complicated by the development of benign stricture. Most strictures are amenable to dilation, but refractory strictures may require surgical intervention. A 24-month-old boy born with tracheoesophageal fistula and EA underwent surgical repair on day 1 of life. He developed esophageal stricture that responded to esophageal stent placement. Endoscopic biliary accessories can be safely used to dilate refractory esophageal strictures in children, and should be considered prior to seeking other complex alternatives.

Endoscopy-guided balloon dilation of benign anastomotic strictures after radical gastrectomy for gastric cancer

Background/Aims

The aim of this study was to evaluate the outcome of endoscopic dilation for benign anastomotic stricture after radical gastrectomy in gastric cancer patients.

Methods

Gastric cancer patients who underwent endoscopic balloon dilation for benign anastomosis stricture after radical gastrectomy during a 6-year period were reviewed retrospectively.

Results

Twenty-one patients developed benign strictures at the site of anastomosis. The majority of strictures occurred within 1 year after surgery (95.2%). The median duration to stenosis after surgery was 1.70 months (range, 0.17 to 23.97 months). The success rate of the first endoscopic dilation was 61.9%. Between the restenosis group (n=8) and the no restenosis group (n=13), there were no significant differences in the body mass index (22.82 kg/m² vs 22.46 kg/m²), interval to symptom onset (73.9 days vs 109.3 days), interval to treatment (84.6 days vs 115.6 days), maximal balloon diameter (14.12 mm vs 15.62 mm), number of balloon dilation sessions (1.75 vs 1.31), location of gastric cancer or type of surgery. One patient required surgery because of stricture refractory to repeated dilation.

Conclusions

Endoscopic dilation is a highly effective treatment for benign anastomotic strictures after radical gastrectomy for gastric cancer and should be considered a primary intervention prior to proceeding with surgical revision.

Clinical value of preventive balloon dilatation for esophageal stricture

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) were developed for the treatment of benign lesions and early superficial esophageal cancers in the gastrointestinal (GI) tract. However, esophageal strictures frequently develop in patients who undergo EMR/ESD. Therefore, we aimed to investigate the clinical value of preventive balloon dilatation (BD) for esophageal diseases following endoscopic therapy. A total of 30 patients who had received EMR or ESD were enrolled in the study. Preventive BD was carried out for 12 cases within 1 week following EMR/ESD. The remaining 18 cases were not subjected to preventive BD and were used as an historic control. The results revealed that no complications, including esophageal stenosis and dysphagia, were observed in the patients who received preventive BD. In the control group, seven cases experienced dysphagia, of which two were released without clinical treatment and the other five were released following two or three BD procedures. The results indicate that preventive BD is an effective treatment for patients with esophageal diseases following EMR and should be considered at an early stage when the mucosal injury exceeds two-thirds of the esophageal lumen.

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.

Long-term outcome after proximal gastrectomy with jejunal interposition for suspected early cancer in the upper third of the stomach

Background

Proximal gastrectomy was introduced as a function-preserving operation for early gastric cancer (EGC). The aim of this study was to investigate long-term outcomes after this procedure.

Methods

Between 1993 and 2005, patients with suspected EGC in the upper third of the stomach underwent proximal gastrectomy. The long-term oncological and surgical outcomes were assessed.

Results

Of 128 patients thought to have EGC, 14 had advanced disease. Nodal involvement was seen in 13 patients (10·2 per cent). Postoperative complications developed in 20 (15·6 per cent). Anastomotic stricture was the most frequent complication, occurring in 13 patients (10·2 per cent). There were no postoperative deaths. During follow-up, nine patients (7·0 per cent) were hospitalized owing to bowel obstruction. Eight (6·3 per cent) developed a second primary gastric carcinoma. The overall 5-year survival rate was 90·5 per cent.

Conclusion

Proximal gastrectomy is well tolerated, with excellent outcomes in patients with suspected EGC. It is recommended as a standard procedure for the treatment of EGC in the upper third of the stomach.

Fluoroscopically guided balloon dilation for benign anastomotic stricture in the upper gastrointestinal tract

A benign anastomotic stricture is a common complication of upper gastrointestinal (UGI) surgery and is difficult to manage conservatively. Fluoroscopically guided balloon dilation has a number of advantages and is a safe and effective procedure for the treatment of various benign anastomotic strictures in the UGI tract.

The use of self-expanding silicone stents in esophagectomy strictures: less cost and more efficiency

BACKGROUND

Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation.

METHODS

A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable silicone-covered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared.

RESULTS

The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months' duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations.

CONCLUSIONS

In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.