Indications for endoscopic neodymium-YAG laser treatment in the gastrointestinal tract. Twelve years' experience

Multi-disciplinary approach for management of refractory benign occlusive esophageal strictures

BACKGROUND

Benign occlusive esophageal strictures create substantial morbidity and have poor surgical outcomes. Various endoscopic techniques have been described to manage these strictures. The challenge remains to maintain adequate long-term esophageal patency and to limit the need for serial endoscopic dilations. Little has been reported regarding the management of these benign occlusive strictures.

METHODS

We report a case series describing the management of technically challenging benign occlusive esophageal strictures. Three patients with occlusive esophageal strictures of differing etiologies were treated using a variety of endoscopic methodologies.

RESULTS

The first patient sustained a caustic oropharyngeal injury resulting in a proximal esophageal stricture which was treated by using a combined antegrade retrograde dilation (CARD) with argon plasma coagulation (APC) and needle knife dissection resulting in the successful recanalization and patency of his stricture. A second patient developed an esophageal stricture following radiotherapy, and was treated with a CARD procedure and serial balloon dilations in combination with APC to successfully achieve esophageal luminal patency. The final patient acquired an occlusive esophageal stricture after treatment for thyroid cancer which was treated with endoscopic needle knife dissection followed by serial balloon dilations to successfully manage this stricture.

CONCLUSIONS

Occlusive esophageal strictures pose a difficult challenge to gastroenterologists and little has been reported with regards to their endoscopic management. Using the CARD technique, needle knife dissection and APC, individually or in combination, luminal patency of occlusive esophageal strictures can be accomplished safely with good results.

Lasers in anorectal surgery

Laser technology has been applied widely in the treatment of hemorrhoids, condylomas, and anorectal neoplasms. It is claimed by its proponents to result in less pain, improved healing, and more rapid recovery as compared with conventional surgery. Laser therapy, however, is expensive and potentially dangerous, and advantages generally have not been substantiated by controlled clinical trials. The possible benefits and potential risks of laser treatment of anorectal disorders are examined.

Endoscopic laser therapy for neoplastic lesions of the colorectum

Surgical resection is the therapy of choice for most colorectal neoplasms. Endoscopic laser therapy (ELT) is a recently developed alternative for treatment of colorectal neoplasms and is applicable in a variety of clinical circumstances in which nonoperative treatment is preferable. The experience with ELT using the Nd:YAG (neodynium:yttrium-aluminum-garnet) laser in 42 patients was analyzed. The diagnosis was colorectal adenocarcinoma in 32 patients (76%) and neoplastic polyps in 10 (24%). ELT was undertaken either as a palliative treatment for malignant disease (60%), with curative intent for benign disease (26%), or as a temporizing measure (14%) in a total of 84 treatment sessions. Successful palliation or cure was achieved in 40 patients (95%) with 4 minor complications (9%) and no procedure-related deaths. This experience confirms ELT as an effective alternative to surgical therapy in the palliative, curative, or interim treatment of certain colorectal neoplasms in patients with prohibitive operative risk, limited anticipated survival, incurability, or diffidence toward operation.

Endoscopic laser applications in the gastrointestinal tract

The Nd:YAG and, to a lesser degree, the argon laser have become valuable tools for the surgical endoscopist. Over the last 10 years, the impetus for application of these expensive instruments has changed from what the laser can do to what the laser can do better than less expensive technology. Whereas a few controlled randomized studies suggest that the Nd:YAG laser is better than no therapy and equivalent to other heat-producing instruments for control of upper gastrointestinal bleeding, such studies do not exist for other laser applications. Despite the lack of such studies, we remain convinced that, where available, lasers are the instrument of choice for palliation of unresectable mucosal-based cancers, coagulation of arteriovenous malformations, and ablation of certain adenomatous polyps in selected patients. New techniques on the horizon include the use of endoscopic photo-dynamic therapy for treatment of gastrointestinal cancers and endoscopic laser fragmentation of large common bile duct stones. The potential role for a nonthermal "endoscopic scalpel" is questionable because most gastrointestinal tissues are well vascularized; however, a pulsed laser capable of cutting and coagulation, such as the holmium:YAG laser, may be of some value for incisional endoscopic procedures.