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Mathew J, Kazi M, Sukumar V, Thakur S, Desouza A, Saklani A. Factors predicting successful resolution and long-term outcomes of benign anastomotic strictures following rectal cancer surgery. Eur J Surg Oncol 2023; 49:1307-1313. [PMID: 36918333 DOI: 10.1016/j.ejso.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/25/2022] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
AIM Although advances in treatment have improved sphincter-preservation rates in rectal cancer, the incidence of benign anastomotic strictures has also increased. This retrospective single-institution study sought to determine the incidence of benign anastomotic strictures and the factors associated with their successful resolution following treatment. METHODOLOGY From January 2010 to December 2019, consecutive patients undergoing endoscopic dilatation and/or surgery for benign anastomotic strictures developing after radical sphincter-sparing resections for rectal cancer were evaluated. To model the relationship between outcomes and potential independent variables, sequential univariate and multivariate analyses were performed using binary logistic regression. RESULTS Of 2069 rectal cancer patients undergoing sphincter-preserving surgery, benign anastomotic strictures were identified in 110 (5.3%). Mean age was 48.2 ± 13.98 years; 73.6% were male. Distal tumor-extent was within 6 cm of the anal verge in 60%; 80.9% patients received neoadjuvant radiotherapy. Surgical approach in 71.8% was open, 74.5% being anterior or low anterior resections and 70.9% of anastomoses stapled. Covering stoma was performed in 91.8%. On follow-up, strictures of median length 4 cm were identified at median 3 cm from the anal verge. Endoscopic dilatation was offered in 89.1%, whereas 9.1% required redo-surgery. Overall, 49.1% experienced sustained stricture-resolution with dilatation and 45.4% required re-intervention. At last follow-up, 72.7% were stoma-free. On multivariate analysis, good performance status, absence of anastomotic leak, and short-segment strictures predicted successful stricture-resolution. CONCLUSION Endoscopic dilatation is an effective first-line therapy, with redo anastomosis used to salvage those failing conservative measures. Adverse performance status, anastomotic leak and greater stricture length may predict detrimental outcomes in terms of stricture resolution.
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Affiliation(s)
- Joseph Mathew
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Mufaddal Kazi
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Vivek Sukumar
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Swarnim Thakur
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Ashwin Desouza
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
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Di Maggio F, Vergani V, Tomasi I, Zhang C, Gossage J, Botha A, Baker C. Assessment and management after corrosive ingestion: when is specialist centre referral needed? A 10-year UK experience. Surg Endosc 2022. [PMID: 35411459 DOI: 10.1007/s00464-022-09174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Corrosive ingestion injuries are rare but clinically significant events, potentially associated with high morbidity and mortality. The low volume of cases limits guideline development. We report a 10-year experience of our tertiary centre focusing on cases requiring specialist care. METHODS All adults treated following corrosive ingestion between 2010 and 2020 were included. Blood results, imaging and endoscopic findings were reviewed. Patients were stratified based on endoscopic findings. Emergency and delayed management was analysed along with short and long-term outcomes. Predictive value of early outcome indicators was investigated. RESULTS Eighty-one patients were included, with an average follow-up of 5 years. Patients with injuries ≤ Zargar 2A (n = 15) had long-term outcomes similar to the ones with negative endoscopic findings (n = 51). All fifteen patients suffering injuries Zargar ≥ 2B required ITU and four died (26.6%). All deaths occurred within 50 days of ingestion, had Zargar grade ≥ 3 and airway involvement. Five patients (33%) required emergency operations, two of which died. All Zargar ≥ 2B injury survivors (n = 11) developed strictures and/or tracheo-esophageal fistulae (18%), required multiple admissions and prolonged nutritional support; five required delayed resections. Zargar grade ≥ 2B, airway damage, and increased CRP on admission correlated with unfavourable outcomes. CONCLUSION Corrosive ingestion injuries up to Zargar 2A do not cause long-term sequelae and can be managed locally. Injuries > 2B bear high mortality and will cause sequelae. Early identification of severe injuries and transfer to specialist centres with multidisciplinary ITU, OG, thoracic and ENT expertise is recommended.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lye TJY, Eng AKH. Late Stricture from Marginal Ulceration after Roux-en-Y Gastric Bypass: Endoscopic Complications and Surgical Management. Obes Surg 2021; 31:5508-5509. [PMID: 34570307 DOI: 10.1007/s11695-021-05716-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Tiffany Jian Ying Lye
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Outram Road, 169608, Singapore, Singapore.
| | - Alvin K H Eng
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Outram Road, 169608, Singapore, Singapore
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El-Asmar KM, Allam AM. Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations? J Pediatr Surg 2021; 56:1596-1599. [PMID: 32943196 DOI: 10.1016/j.jpedsurg.2020.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Caustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not. METHODS We retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program. RESULTS The patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program. CONCLUSION A length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - Ayman M Allam
- Pediatric Surgery Department, Ain Shams University, Cairo, Egypt
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Tarek S, Mohsen N, Abd El-Kareem D, Hasnoon A, Abd El-Hakeem A, Eskander A. Factors affecting the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture in Egyptian children: a single-centre study. Esophagus 2020; 17:330-338. [PMID: 32088785 DOI: 10.1007/s10388-020-00727-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 02/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND An important complication of corrosive ingestion is oesophageal stricture. Improvements in endoscopes and accessories have supported an increase in the number of patients who are conservatively treated with endoscopic dilations. In this study, we aimed to detect factors affecting the outcome of endoscopic dilatation for refractory post-corrosive oesophageal stricture. METHODS This study was carried out in the Paediatric Endoscopy Unit in the Children's Hospital and included 100 children older than 2 years of age of both sexes who had an established diagnosis of post-corrosive oesophageal stricture on repeated endoscopic dilatation sessions. The duration of the condition was more than 6 months, and dilatation failed to achieve a diameter of 14 mm during the first five sessions at 2-week intervals (refractory), excluding other causes of oesophageal stricture. RESULTS Males represented 63% of patients. The mean age of enrolled children was 5.9 ± 2.6 years; 90% of patients ingested an alkaline corrosive substance (potash). The total number of dilatation sessions ranged from 16 to 100, with a mean number of sessions ranging from 37.2 ± 14.9. Fifty-four patients (54%) were well controlled by regular endoscopic dilatation with good clinical and endoscopic outcomes, and no more dilatations were needed. CONCLUSION Endoscopic dilation is an effective method for managing refractory post-corrosive oesophageal strictures that require a long follow-up period. There are a lot of factors affecting the outcome.
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Affiliation(s)
- Sara Tarek
- Department of Paediatrics, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt.
| | - Nabil Mohsen
- Department of Paediatrics, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt
| | - Dalia Abd El-Kareem
- Department of Pathology, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt
| | - Amera Hasnoon
- Department of Paediatrics, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt
| | - Asmaa Abd El-Hakeem
- Department of Paediatrics, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt
| | - Ayman Eskander
- Department of Paediatrics, KasrAlainy School of Medicine, Cairo University, Cairo, Egypt
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Joshi P, Yadav R, Dangi A, Kumar P, Kumar S, Gupta V, Gupta V, Chandra A. Corrosive Esophageal Strictures: From Dilatation to Replacement: A Retrospective Cohort Study. Dysphagia 2019; 35:558-567. [PMID: 31485830 DOI: 10.1007/s00455-019-10058-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/21/2019] [Indexed: 01/21/2023]
Abstract
Endoscopic dilatation is the recommended primary therapy for chronic corrosive esophageal strictures (ES), and surgery is reserved for failed dilatation. Through this study, we intend to analyze the efficacy and long-term outcomes of both endoscopic and surgical interventions in corrosive ES. A retrospective cohort analysis of patients with chronic corrosive ES, managed with endoscopic or surgical procedures at a tertiary teaching institute in North India from December 2009 to December 2016, was performed from a prospectively maintained database. The primary outcome measure was the absence of dysphagia following dilatation or surgery. During the study period, 64 patients with ES underwent surgical or endoscopic treatment. Associated gastric strictures and pharyngeal strictures were present in 39 (60%) and 22 patients (28.9%), respectively. The mean age was 28.8 years and mean BMI was 14.2 kg/m2. Acid was the most common corrosive substance. Endoscopic dilatation using Savary-Gilliard (SG) dilators was successful in achieving persistent symptom relief in 46 patients (71.8%) after a total of 358 sessions (mean number of dilatations were 5.2 ± 1.2) of dilatations over 2 years. The dilatation therapy failed in 18 patients (28.1%) including technical failures (15.6%), perforations (3.1%), refractory stricture (1.5%) and recurrent strictures (7.8%). Increasing stricture length (more than 6 cm) was associated with poor outcome of endoscopic dilatation (p < 0.001). Only eleven patients (17%) required esophageal replacement (resection: 0, bypass: 11) for failed dilatations including seven gastric pull-ups and four pharyngo-coloplasty. The stricture rate after surgery was 36.3% (4/11). The median follows up was 32 months. Endoscopic dilatation of corrosive ES is safe and effective therapy and should be the first-line therapy for these patients and surgery should be considered only in patients who have unsuccessful outcome following dilatation therapy.
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Affiliation(s)
- Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Rakesh Yadav
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Amit Dangi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Pavan Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Vivek Gupta
- Department of Human Organ Transplant, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India.
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Eskander A, Ghobrial C, Mohsen NA, Mounir B, Abd EL-Kareem D, Tarek S, El-Shabrawi MHF. Histopathological changes in the oesophageal mucosa in Egyptian children with corrosive strictures: A single-centre vast experience. World J Gastroenterol 2019; 25:870-879. [PMID: 30809086 PMCID: PMC6385009 DOI: 10.3748/wjg.v25.i7.870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/17/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The caustic ingestion continues to be a major problem worldwide especially in developing countries. The long-term complications include stricture and increased life time risk of oesophageal carcinoma. Patients suffered from corrosive induced oesophageal strictures have more than a 1000-fold risk of developing carcinoma of the oesophagus.
AIM To determine the possibility of oesophageal mucosal dysplasia after prolonged dilatation in post corrosive stricture.
METHODS This observational study was conducted at the Paediatric Endoscopy Unit in Cairo University Children’s Hospital. It included children of both sexes older than 2 years of age who had an established diagnosis of post-corrosive oesophageal stricture and repeated endoscopic dilatation sessions for more than 6 mo. All patients were biopsied at the stricture site after 6 mo of endoscopic dilatation. A histopathological examination of an oesophageal mucosal biopsy was performed for the detection of chronic oesophagitis, inflammatory cellular infiltration and dysplasia.
RESULTS The mean age of the enrolled children was 5.9 ± 2.6 years; 90% of the patients had ingested an alkaline corrosive substance (potash). The total number of endoscopic dilatation sessions were ranging from 16 to 100 with mean number of sessions was 37.2 ± 14.9. Histopathological examination of the specimens showed that 85% of patients had evidence of chronic oesophagitis (group A) in the form of basal cell hyperplasia, hyperkeratosis and subepithelial fibrosis. Thirteen percent of the patients had evidence of reactive atypia (group B) in the form of severe neutrophilic intraepithelial inflammatory cellular infiltration, and 2 patients (2%) had mild squamous dysplasia (group C); we rebiopsied these two patients 6 mo after the initial pathological assessment, guided by chromoendoscopy by Lugol's iodine.
CONCLUSION The histopathology of oesophageal mucosal biopsies in post-corrosive patients demonstrates evidence of chronic oesophagitis, intraepithelial inflammatory cellular infiltration and dysplasia. Dysplasia is one of the complications of post-corrosive oesophageal stricture.
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Affiliation(s)
- Ayman Eskander
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Carolyne Ghobrial
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Nabil A Mohsen
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Bahaa Mounir
- Department of Pathology, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Dalia Abd EL-Kareem
- Department of Pathology, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Sara Tarek
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Mortada HF El-Shabrawi
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
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Sartori A, De Luca M, Fiscon V, Frego M; CANSAS study working group; Portale G. Retrospective multicenter study of post-operative stenosis after stapled colorectal anastomosis. Updates Surg. 2019;71:539-542. [PMID: 30073626 DOI: 10.1007/s13304-018-0575-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/23/2018] [Indexed: 01/27/2023]
Abstract
Anastomotic stenosis after colorectal surgery is usually considered low-rate complication and often is under-reported in most studies. Few data are available on management strategies. The aim of the study was to assess the prevalence of stenosis after stapled colorectal anastomosis, performed either in elective or emergent setting, for benign or malignant disease, and to evaluate treatment profiles. This retrospective study was a survey conducted in a large Italian North-Eastern area including three regions (Triveneto), over a 12-month period (January-December 2015). Patients' characteristics and surgical technique details were recorded, along with data on the prevalence of stenosis and its treatment. Patients with mid or low rectal resection and/or neoadjuvant chemo-radio therapy and/or diverting stoma were excluded. The study was promoted by the Italian Association of Hospital Surgeons (ACOI) and the Society of Surgeons of the Triveneto Region. Twenty-eight surgical units were enrolled in the survey, accounting for over 1400 patients studied. Fifty percent of the units performed laparoscopically > 70% of the colorectal resections and 7.5% of the procedures were emergent. Less than 60% of the units planned regular endoscopic follow-up after colorectal resection. Anastomotic stricture was recorded in 2% of the patients; 88% of the stenoses were diagnosed within 6 months from surgery. Only one anastomotic stricture required re-do surgery. The CANSAS study confirms that colorectal anastomotic stenosis is low-rate-but still present-complication. Treatment strategies vary according to surgeons' and endoscopists' preferences. Commonly endoscopic dilatation is preferred, but re-do surgery is required in some cases.
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Gambardella C, Allaria A, Siciliano G, Mauriello C, Patrone R, Avenia N, Polistena A, Sanguinetti A, Napolitano S, Conzo G. Recurrent esophageal stricture from previous caustic ingestion treated with 40-year self-dilation: case report and review of literature. BMC Gastroenterol 2018; 18:68. [PMID: 29788901 PMCID: PMC5964928 DOI: 10.1186/s12876-018-0801-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 05/15/2018] [Indexed: 12/14/2022] Open
Abstract
Background Corrosive esophageal strictures are common. The severity of the strictures depends on type, quantity, duration of contact and concentration of the caustic substance ingested. Endoscopic balloon dilation and endoscopic bougienage are a cornerstone in the management of the benign esophageal strictures and are the most widely used treatments, but are expensive and invasive procedures. Case Presentation We report the case of an 82-year-old patient with a corrosive esophageal stricture treated for over 40 years by means of home self-bougienage. The procedure has been carried out for the longest lapse of time described in literature, with an excellent control of symptoms. In the case reported, after being carried out for more than 40 years, self-dilation allowed good quality of life and symptoms management, ensuring an excellent nutritional status. Conclusions Following an adequate patient training, self-dilatation can be a safe and effective option of treatment, avoiding frequent expensive hospital admissions for endoscopic esophageal dilatation.
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Affiliation(s)
- C Gambardella
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy.
| | - A Allaria
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
| | - G Siciliano
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
| | - C Mauriello
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
| | - R Patrone
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
| | - N Avenia
- Endocrine Surgery Unit, University of Perugia, Perugia, Italy
| | - A Polistena
- Endocrine Surgery Unit, University of Perugia, Perugia, Italy
| | - A Sanguinetti
- Endocrine Surgery Unit, University of Perugia, Perugia, Italy
| | - S Napolitano
- Italian Air Force Medical Corps, Ministry of Defence, Rome, Italy
| | - G Conzo
- Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
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Bertocchi E, Barugola G, Benini M, Bocus P, Rossini R, Ceccaroni M, Ruffo G. Colorectal Anastomotic Stenosis: Lessons Learned after 1643 Colorectal Resections for Deep Infiltrating Endometriosis. J Minim Invasive Gynecol 2018; 26:100-104. [PMID: 29678755 DOI: 10.1016/j.jmig.2018.03.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To evaluate the incidence, risk factors, and treatment of colorectal anastomotic stenosis in patients who undergo rectosigmoid resection for deep infiltrating endometriosis (DIE). DESIGN Retrospective analysis of a prospective database (Canadian Task Force classification III). SETTING Public medical center. PATIENTS All women who underwent laparoscopic rectosigmoid resections for DIE at our hospital between January 2002 and December 2016. INTERVENTION All patients were evaluated clinically and endoscopically at 1 month and 3 months after bowel resection. Stenosis was defined as a lack of passage through the anastomosis of a 12-mm proctoscope. Symptomatic stenosis was defined as the presence of endoscopically confirmed stricture accompanied by at least 2 of the following symptoms: constipation, need to push, tenesmus, and ribbon stools. Only patients with symptomatic stenosis were studied. Demographic data, surgical techniques, and postoperative complications were recorded prospectively. Treatments and outcomes of anastomotic symptomatic strictures were analyzed. MEASUREMENTS AND MAIN RESULTS A total of 1643 patients underwent laparoscopic rectosigmoid resection at our hospital between January 2002 and December 2016. Among these, 104 patients (6.3%) presented with symptomatic anastomotic stenosis. The median patient age was 27 years (range, 23-44 years), and the median interval between diagnosis and the onset of symptomatic stenosis was 57 days (range, 21-64 days). The only statistically significant predictors of anastomotic stenosis were the presence of ileostomy (p = .01) and previous pelvic surgery (p = .002). Treatment of choice was always conservative. Of the 104 patients in the study cohort, 90 (86.5%) underwent 3 endoscopic dilatations. No patient required reoperation. CONCLUSION The anastomotic stricture is a recognized complication in patients following intestinal resection for DIE, and protective ileostomy is the sole modifiable factor related to anastomotic stenosis. Endoscopic dilatation is a valid option to treat this complication.
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Affiliation(s)
- Elisa Bertocchi
- Department of Surgery, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy.
| | - Giuliano Barugola
- Department of Surgery, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
| | - Marco Benini
- Department of Gastroenterology and Endoscopy, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
| | - Paolo Bocus
- Department of Gastroenterology and Endoscopy, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
| | - Roberto Rossini
- Department of Surgery, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
| | - Marcello Ceccaroni
- Department of Gynecology, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
| | - Giacomo Ruffo
- Department of Surgery, Sacred Heart-Don Calabria Hospital, Negrar, Verona, Italy
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Michalak A, Cichoż-Lach H, Prozorow-Król B, Buk L, Dzida M. A rare case of skin blistering and esophageal stenosis in the course of epidermolysis bullosa - case report and literature review. BMC Gastroenterol 2018; 18:47. [PMID: 29653516 PMCID: PMC5899341 DOI: 10.1186/s12876-018-0771-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 03/20/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Epidermolysis bullosa (EB) constitutes a heterogenous group of rare multisystem genetically transmitted disorders comprising several blistering muco-cutaneous diseases with a monogenic basis and either autosomal dominant or autosomal recessive mode of inheritance. EB manifestation is not only limited to the skin. Systemic signs might involve the nose, ear, eye, genitourinary tract and upper gastrointestinal tract. The presence of particular symptoms is directly determined by a type of altered skin protein. Gastrointestinal manifestation of EB is most commonly reflected by esophageal stenosis due to recurrent esophageal blistering, followed by consequent scarring. CASE PRESENTATION Here we present a case of a man with dystrophic EB and dysphagia, skin blistering, joints contractures and missing nails. To our knowledge, the presented man is the oldest one diagnosed with EB living in Poland. CONCLUSIONS Management of an esophageal stricture in such circumstances is based on endoscopic dilatation. However, in most severe cases, placement of a gastrostomy tube is required. Despite great advances in medicine, a targeted therapy in the course of EB has not been established yet.
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Affiliation(s)
- Agata Michalak
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Jaczewski Str, Lublin, 820-954, Poland
| | - Halina Cichoż-Lach
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Jaczewski Str, Lublin, 820-954, Poland.
| | - Beata Prozorow-Król
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Jaczewski Str, Lublin, 820-954, Poland
| | - Leszek Buk
- Department of Radiology and Nuclear Medicine, Medical University of Lublin, Jaczewski Str, Lublin, 820-954, Poland
| | - Monika Dzida
- Department of Radiology and Nuclear Medicine, Medical University of Lublin, Jaczewski Str, Lublin, 820-954, Poland
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Deslauriers V, Beauchamp A, Garofalo F, Atlas H, Denis R, Garneau P, Pescarus R. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surg Endosc 2017; 32:601-609. [PMID: 28726143 DOI: 10.1007/s00464-017-5709-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 07/05/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery worldwide. Gastric sleeve stenosis is the most common postoperative complication, occurring in up to 3.9% of the cases. Current treatment options include endoscopic treatments, such as dilatations and stent placement as well as surgical revisions such as laparoscopic Roux-en-Y gastric bypass (LRYGB), wedge gastrectomy or seromyotomy. METHODS A retrospective analysis of our prospectively collected therapeutical endoscopy database was performed between January 2014 and February 2017. We included all cases of axial deviation or stenosis post LSG, which were treated endoscopically. Patients with concomitant sleeve leaks were excluded. Endoscopic interventions were performed under general anaesthesia and fluoroscopic assistance when needed. Sequential treatment with CRE balloons, achalasia balloons (30-40 mm) and fully covered stent placement for refractory cases was performed. RESULTS A total of 1332 LSG were performed. Overall, 27/1332 patients (2%) developed a gastric stenosis. All patients presented an axial deviation at the incisura angularis and 26% had a concomitant proximal stenosis. Successful endoscopic treatments were performed in 56% (15/27) of patients, 73% of the successful patients underwent a single dilatation procedure. All successful cases had a maximum of 3 interventions. The unsuccessful cases (44%) underwent LRYGB. Mean time between the primary surgery and the diagnosis of the stenosis was 10.3 months. Mean follow-up after the endoscopic treatment was 11.5 months. A stent migration was the only complication (3.7%) recorded. CONCLUSIONS Endoscopic treatment appears to be effective in 56% of patients with post-LSG stenosis. Only one session of achalasia balloon dilatation is necessary in 73% of successful cases. Pneumatic balloon dilatation seems to be a safe procedure in this patient population. Surgical revision into a LRYGB offers good outcomes in patients that have failed three consecutive endoscopic treatments.
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Affiliation(s)
- Valérie Deslauriers
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Amélie Beauchamp
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Fabio Garofalo
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Henri Atlas
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Ronald Denis
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Pierre Garneau
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Radu Pescarus
- Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Département de Chirurgie, Université de Montréal, 5400 Boul. Gouin Ouest, Montréal, QC, H4J 1C5, Canada.
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Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie R, Regimbeau JM. Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management. Obes Surg 2016; 26:995-1001. [PMID: 26363902 DOI: 10.1007/s11695-015-1883-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication. METHODS We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data. RESULTS During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4%); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1-114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2%) after balloon dilatation (n = 13) or insertion of a covered stent (n = 2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8%). CONCLUSION GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.
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Liew YT, Soo SS, Nathan AM, Manuel AM. Congenital nasal cavity stenosis in children with craniosyntosis: A report of 4 rare cases. Auris Nasus Larynx 2016; 44:635-638. [PMID: 27793496 DOI: 10.1016/j.anl.2016.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 09/17/2016] [Accepted: 10/06/2016] [Indexed: 11/18/2022]
Abstract
Congenital bony nasal stenosis (CBNS) is a very rare but life-threatening cause of airway obstruction in neonates and infants. This review aims to assess the presentation and early airway management of 4 new cases of craniosynostosis with bilateral nasal cavity stenosis. Patients were treated with endoscopic endonasal widening of the nasal cavity and stenting. All patients were extubated well post-operatively with resolution of symptoms. They remained asymptomatic with stents in situ for at least 6 months with no complications reported. Minimally invasive endoscopic endonasal widening of the nasal cavity with stenting is an effective and safe way of addressing nasal cavity stenosis.
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Affiliation(s)
- Yew Toong Liew
- Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Siew Shuin Soo
- Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Anna Marie Nathan
- Department of Paediatrics, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Anura Michelle Manuel
- Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.
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Kocdor P, Siegel ER, Suen JY, Richter G, Tulunay-Ugur OE. Comorbidities and factors associated with endoscopic surgical outcomes in adult laryngotracheal stenosis. Eur Arch Otorhinolaryngol 2015; 273:419-24. [PMID: 26335288 DOI: 10.1007/s00405-015-3750-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
This study which is a retrospective chart review aims to characterize the comorbidities associated with adult laryngotracheal stenosis and evaluate the relationship of these with stenosis grade, length, surgical interventions, and surgical intervals. Patients' demographics, medical and surgical comorbidities, grade of stenosis, quantity and degree of balloon dilations, dilation intervals, open airway procedures, and tracheotomy status were recorded from 2002 to 2012, at a tertiary voice and airway center. Surgical outcomes were evaluated in relation to patient comorbidities, stenosis quality, and surgical procedures. A total of 101 patients with laryngotracheal stenosis were examined with female patients comprising 71 % of the population. Seventeen patients (16.8 %) had idiopathic stenosis. Number of balloon dilations ranged from 0 to 24 (mean = 3.3). The average time between dilations was 38.4 weeks (range = 1.14-215.8 weeks). The patients with idiopathic stenosis were found to have a lower grade (p = 0.0066). Fifty-two patients (51.5 %) received a tracheotomy at one point during their management. The 14 patients (13.9 %) who remained tracheotomy dependent had a body mass index (BMI) of >30. No statistically significant correlation was found when the patients' age, BMI and comorbidites were compared with the grade of stenosis, number of balloon dilatations needed and other surgical interventions. On the other hand, interval in between surgeries was found to be longer in patients without an intubation history, and in idiopathic SGS (p = 0.004, p = 0.015, respectively). There was no significant relationship between surgical interval and gender, BMI, length of stenosis, grade (p = 0.059, p = 0.47, p = 0.97, p = 0.36, respectively). Airway stenosis in adults is complicated by the presence of multiple comorbidities. Better understanding of the etiology could aid in the prevention of the injury before it forms.
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Affiliation(s)
- Pelin Kocdor
- Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 543, Little Rock, AR, 72205, USA
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, USA
| | - James Y Suen
- Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 543, Little Rock, AR, 72205, USA
| | - Gresham Richter
- Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 543, Little Rock, AR, 72205, USA
| | - Ozlem E Tulunay-Ugur
- Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 543, Little Rock, AR, 72205, USA.
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Oh SK, Park KN, Lee SW. Long-term results of endoscopic dilatation for tracheal and subglottic stenosis. Clin Exp Otorhinolaryngol 2014; 7:324-8. [PMID: 25436054 DOI: 10.3342/ceo.2014.7.4.324] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/20/2013] [Accepted: 06/18/2013] [Indexed: 11/22/2022] Open
Abstract
Objectives The purpose of this study was to assess the long-term results of endoscopic dilatation of airway stenosis and to evaluate predictive factors for favorable results. Methods Fifty-four patients with tracheal and subglottic stenosis who underwent endoscopic dilatation with at least 12 months follow-up were enrolled in this study. We evaluated predictive factors for final treatment outcome such as stenosis length, location, characteristics, procedure type, and the severity of stenosis. Results The final outcome of endoscopic dilatation showed a cure rate of 40.7%, improvement rate of 46.3%, and failure rate of 13.0%. Patients with mild stenosis or a shorter stenotic segment and those who underwent a touch-up procedure following tracheal resection with end-to-end anastomosis showed better outcomes. The cure rate of endoscopic dilatation for patients with shorter mild stenosis was 72.2%. Conclusion Endoscopic dilatation may be a primary treatment modality for patients with airway stenosis characterized by mild severity and a short stenotic segment.
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El-Asmar KM, Hassan MA, Abdelkader HM, Hamza AF. Topical mitomycin C application is effective in management of localized caustic esophageal stricture: a double-blinded, randomized, placebo-controlled trial. J Pediatr Surg 2013; 48:1621-7. [PMID: 23895984 DOI: 10.1016/j.jpedsurg.2013.04.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/26/2013] [Accepted: 04/26/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frequent sessions of endoscopic dilatation are usually required in the management of benign esophageal strictures, especially caustic induced ones. Topical mitomycin C (MMC) has been recently used in the management of resistant strictures. This study evaluated the efficacy of MMC application in prevention of stricture recurrence after endoscopic dilatation. PATIENTS AND METHODS This double-blind, randomized, placebo-controlled trial included forty patients with caustic esophageal strictures dating from January 2008 to October 2010. Patients were randomized into 2 groups to undergo endoscopic dilatation with application of either MMC versus placebo on stricture site. Regular follow up and re-evaluation were done after 6 months of management. The number of dilatation sessions needed for resolution of dysphagia in each group was our primary outcome. RESULTS During the specified follow up period, 80 % of strictures in the MMC group got completely resolved compared to only 35% in the placebo group. The mean number of dilatation sessions needed in the MMC group was n = 3.85 ± 2.08 compared to n = 6.9 ± 2.12 in the placebo group which was statistically significant (p < 0.001). CONCLUSION Mitomycin C application significantly reduced the number of dilatation sessions needed to alleviate dysphagia in patients with caustic esophageal strictures.
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El-Asmar KM. Topical Mitomycin C application for esophageal stricture: safe, precise, and novel endoscopic technique. J Pediatr Surg 2013; 48:1454-7. [PMID: 23845649 DOI: 10.1016/j.jpedsurg.2013.03.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE The first line of management of benign esophageal stricture is endoscopic dilatation; however, multiple sessions are usually indicated especially in resistant cases. Topical Mitomycin C (MCC) application is a new adjuvant treatment in the management of esophageal stricture with promising results in different case series. Several techniques have been reported for application; nevertheless, the ideal technique has not been described yet. MATERIAL AND METHODS In this series we have devised a new technique using both the flexible and the rigid endoscope and a specially designed Nelaton catheter. RESULTS This technique was applied in 38 sessions for 16 caustic esophageal strictures with technical success in all cases. No procedure-related complications were observed in this series. CONCLUSION This novel technique is feasible and effective and can be considered as standard for topical MMC application on esophageal stricture.
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Abstract
The major papilla of Vater is usually located in the second portion of the duodenum, to the posterior medial wall. Sometimes the mouth of the biliary duct is located in other areas. Drainage of the common bile duct into the pylorus is extremely rare. A 73-year old man, with a history of duodenal ulcer, was admitted to hospital with the diagnosis of cholangitis. Dilatation of the extrahepatic biliary duct was observed by abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. No area suggesting the presence of the papilla of Vater was found within the second duodenal portion. Finally the major papilla was located in the theoretical pyloric duct. Cholangiography was performed and choledocholithiasis was found in the biliary tree. The patient underwent dilatation of the papilla with a balloon tyre and removal of a 7 mm stone using a Dormia basket, which solved the problem without further complications. This anomaly increased the difficulty of performing therapeutic interventions during ERCP. This alteration in anatomy may increase the risk of complications during papillotomy, with a theoretically higher risk of perforation. Dilatation using a balloon was the chosen therapeutic technique both in our case and in the literature, due to its low rate of complications.
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