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Lu Q, Yan H, Wang Y, Lei T, Zhu L, Ma H, Yang J. The role of endoscopic dilation and stents in refractory benign esophageal strictures: a retrospective analysis. BMC Gastroenterol 2019; 19:95. [PMID: 31221085 PMCID: PMC6585047 DOI: 10.1186/s12876-019-1006-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 05/30/2019] [Indexed: 02/05/2023] Open
Abstract
Background The outcomes of patients with refractory benign esophageal strictures (RBES) are unclear, and the clinical efficacy of dilation versus stent placement is lacking. Our objective was to explore the role of endoscopic dilation and stents placement in the management of RBES. Methods RBES patients treated with dilation and stents in our hospital between January 2009 and December 2017 were included in this study. The primary outcomes were to assess clinical effectiveness and adverse events. The secondary outcome was to identify factors that predicted the dysphagia-free period. Results Among 75 RBES patients (54 male; median age 59 years), 39 (52%), 20 (26.7%), 3 (4%), 10 (13.3%), and 3 (4%), were postsurgical, post-ESD, achalasia of cardia, caustic and mixed etiology, respectively. The median number of endoscopic therapy was 5 times (range 3, 21). Endoscopic therapy was successful in 46 patients (61.3%). Patients treated with dilation showed a higher success rate (70.9%, 39/55) than that treated with stents (35%, 7/20). Fifteen patients died during follow-up. Nineteen patients had adverse events after endoscopic therapy. In total, the mean dysphagia-free period was 3.4 months (95% CI, 2.5–4.3). The patients treated with dilation demonstrated a dysphagia-free period of 3.7 months (95% CI, 2.7–5), while patients treated with stents displayed a dysphagia-free period of 2.3 months (95% CI, 1.5–3). The dysphagia-free period had a linear growth trend over time, with an increase of 12 days per endoscopic therapy. Conclusion The dysphagia-free period increased by 12 days per endoscopic therapy, so the endoscopic therapy tended to be effective in patients with RBES by increasing the dysphagia-free period. However, compared to dilation therapy, stent therapy was not effective in increasing the dysphasia-free period and reducing the times and frequency of dilation. In addition, univariate and multivariate analyses also indicated that etiology may predict the endoscopic therapy outcome. Trial registration This study was retrospectively registered and approved by the Ethics Committee of West China Hospital of Sichuan University (IRB number: ChiCTR1800016321).
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Affiliation(s)
- Qing Lu
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hailin Yan
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yilan Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Tiantian Lei
- Department of Day Surgery, West China hospital of Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Linlin Zhu
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hongsheng Ma
- Department of Day Surgery, West China hospital of Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
| | - Jinlin Yang
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China.
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Richardson T, Naidoo G, Rupasinghe N, Smart H, Bhattacharya S. Biodegradable Stents in Resistant Peptic Oesophageal Stricture: Is It the Right Way to Go? CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2019; 11:1179552218819492. [PMID: 30627002 PMCID: PMC6309028 DOI: 10.1177/1179552218819492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/14/2018] [Indexed: 12/22/2022]
Abstract
Peptic oesophageal stricture can be considered as the end result of prolonged gastro-oesophageal reflux. The 'gold standard' treatment for peptic stricture is endoscopic dilatation with balloon or bougie. It is predicted that up to 40% of patients remain symptomatic with dysphagia due to refractory (resistant to treatment) or recurrent strictures, needing frequent interventions at short intervals. Such patients have poor nutritional status due to the primary disease and are susceptible to complications related to repeated endoscopic dilatation such as bleeding and perforation. This general review aims to analyse existing published evidence and address the role of biodegradable stents in resistant peptic strictures as an alternative treatment to provide long-term dysphagia-free intervals.
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Affiliation(s)
- Tom Richardson
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Gerlin Naidoo
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Namal Rupasinghe
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Howard Smart
- Endoscopy Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Sayantan Bhattacharya
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK.,Consultant Upper GI Surgeon, Warrington, UK.,Department of General Surgery, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
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Clinical Feasibility and Safety of Endoscopic Self-Expandable Metal Stent Placement for Upper Gastrointestinal Pathologies. Int Surg 2018. [DOI: 10.9738/intsurg-d-15-00169.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to review our experiences to evaluate the practicality, safety, and effectiveness of endoscopic stent placement for the palliation of malignant obstructions of the upper gastrointestinal system (GIS) and the treatment of postoperative complications such as failure of anastomoses and fistulae. Endoscopic stent placement is increasingly used in the upper GIS for the management of both high grade malignancies causing obstruction and benign pathologies such as anastomosis failures, gastrointestinal fistulae, and strictures. Hospital records, clinical data, and endoscopy reports of 61 patients who had undergone endoscopic stenting between the years 2012 and 2015 were analyzed retrospectively. For all patients, self-expandable metal covered stents were used. Data involving technical and clinical success rates, complication, morbidity, and mortality rates of the endoscopic stenting procedure was collected and simple statistical analyses were made. Endoscopic stenting was successful in 60 of 61 patients (98.3%). Overall technical success rate was found to be 98.3%; clinical success rate, 86.6%; complication rate, 4.9%. No stent related mortality was observed in our series. Endoscopic stents can be effectively and safely used in the treatment of various lesions of the upper GIS.
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Poincloux L, Rouquette O, Abergel A. Endoscopic treatment of benign esophageal strictures: a literature review. Expert Rev Gastroenterol Hepatol 2017; 11:53-64. [PMID: 27835929 DOI: 10.1080/17474124.2017.1260002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.
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Affiliation(s)
- Laurent Poincloux
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France.,b UMR Auvergne University/CNRS 6284 ISIT (Image Sciences for Innovations Techniques) , Clermont-Ferrand , France
| | - Olivier Rouquette
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France
| | - Armand Abergel
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France.,b UMR Auvergne University/CNRS 6284 ISIT (Image Sciences for Innovations Techniques) , Clermont-Ferrand , France
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Repici A, Small AJ, Mendelson A, Jovani M, Correale L, Hassan C, Ridola L, Anderloni A, Ferrara EC, Kochman ML. Natural history and management of refractory benign esophageal strictures. Gastrointest Endosc 2016; 84:222-8. [PMID: 26828759 DOI: 10.1016/j.gie.2016.01.053] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/23/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES. METHODS Clinical data of consecutive patients with RBES treated in the previous 15 years in 2 tertiary-care referral academic centers with specialized interest in esophageal stricture management were retrospectively analyzed. RBES was defined as the persistence and/or recurrence of dysphagia despite at least 5 dilation sessions and/or cycles with dilation to at least 14 mm. Information regarding the use of dilation or stents and the dysphagia-free period between subsequent interventions and adverse events was collected. Clinical success was defined as no need for endoscopic interventions for at least 6 months; unfavorable outcomes were defined as the need for endoscopic treatment at the end of follow-up, surgery, or percutaneous endoscopic gastrostomy (PEG). Predictors of unfavorable outcomes were assessed by multivariate analysis. A linear mixed-effect model was used to measure dysphagia-free period changes over time. RESULTS Overall, 70 patients with RBES (46 male; mean age 60 years) were followed for a mean of 43.9 months (range 3.7-157 months). Caustic, postradiotherapy, surgical, mixed, and postinflammatory etiology accounted for 10%, 14.3%, 31.4%, 40%, and 4.3% of causes, respectively. All patients underwent sequential sessions of pneumatic or bougie dilation, with a median of 15.5 dilation sessions per patient. Self-expandable metal stents (SEMSs) and biodegradable stents were placed in 18 (25.7%) and 14 (20%) patients, respectively. RBES resolution was achieved in only 22 of 70 (31.4%) patients. Two deaths (3%) were related to RBES. The success rate was lower in those who also were treated with endoprosthetics (odds ratio [OR] 3.7; 95% confidence interval [CI], 1.01-18.0). The mean dysphagia-free period was 3.3 months (95% CI, 2.4-4.1) for patients treated with dilation and 2.4 months (95% CI, 1.2-3.6) for those treated with stents (P = .062). Over time, the total dysphagia-free period increased at a rate of 4.1 days (95% CI, 1.7-6.4) per dilation. There was no difference in the rate of change across groups defined by sex (P = .976), age (P = .633), or endoscopic treatment (P = .267). CONCLUSIONS Our multicenter series showed a disappointing long-term outcome for RBES, with only 1 of 3 achieving clinical resolution. The dysphagia-free period was relatively short, affecting the quality of life. Endoprosthetics did not appear to affect the natural history of RBES.
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Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy; Humanitas University, Milan, Italy
| | - Aaron J Small
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Aaron Mendelson
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | - Michael L Kochman
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Manfredi MA. Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia. Gastrointest Endosc Clin N Am 2016; 26:201-19. [PMID: 26616905 DOI: 10.1016/j.giec.2015.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The reported incidence of anastomotic stricture after esophageal atresia repair has varied in case series from as low as 9% to as high as 80%. The cornerstone of esophageal stricture treatment is dilation with either balloon or bougie. The goal of esophageal dilation is to increase the luminal diameter of the esophagus while also improving dysphagia symptoms. Once a stricture becomes refractory to esophageal dilation, there are several treatment therapies available as adjuncts to dilation therapy. These therapies include intralesional steroid injection, mitomycin C, esophageal stent placement, and endoscopic incisional therapy.
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Affiliation(s)
- Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital, Boston, MA 02132, USA; Pediatrics Harvard Medical School, Boston, MA 02115, USA.
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Gangloff A, Lecleire S, Di Fiore A, Huet E, Iwanicki-Caron I, Antonietti M, Michel P. Fully versus partially covered self-expandable metal stents in benign esophageal strictures. Dis Esophagus 2015; 28:678-83. [PMID: 25168061 DOI: 10.1111/dote.12260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Self-expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long-term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self-expandable metal stents (FCSEMS). We performed a retrospective analysis of self-expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty-two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long-term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.
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Affiliation(s)
- A Gangloff
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - S Lecleire
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - A Di Fiore
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - E Huet
- Department ofDigestive Surgery, Rouen University Hospital, Rouen, France
| | - I Iwanicki-Caron
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - M Antonietti
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
| | - P Michel
- Department ofGastroenterology, Rouen University Hospital, Rouen, France
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8
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Wang S, Wang S, Liu W, Sun S, Liu X, Ge N, Guo J, Wang G, Feng L. The application of linear endoscopic ultrasound in the patients with esophageal anastomotic strictures. Endosc Ultrasound 2015; 4:126-131. [PMID: 26020047 PMCID: PMC4445170 DOI: 10.4103/2303-9027.156740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/16/2015] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To evaluate the role of linear endoscopic ultrasound (EUS) in the diagnosis and treatment of the anastomotic stricture after esophagectomy for locally advanced esophageal cancer (EC). MATERIALS AND METHODS A retrospective analysis was performed in patients undergone EUS assessment and endoscopic treatment for anastomotic stricture after esophagectomy for locally advanced EC from January 2010 to December 2014 at Shengjing Hospital. The linear EUS was performed in all the patients to assess the thickness of the esophageal wall, the length and width of the lesion, and to evaluate the severity of anastomotic stricture. According to the EUS features of the lesion, different endoscopic therapy were performed. RESULTS There were 92 patients enrolled in this study. All the lesions of the patients were assessed by EUS. Eighty-six patients had cicatricial stricture of the esophagus confirmed by EUS, and were treated by endoscopic balloon dilation. Five patients were suspected to have tumor relapses, and the other one had lymphatic metastasis. All the six patients were undergone endoscopic metal stent implantation. The EUS diagnoses of all the patients were confirmed by pathological biopsy. CONCLUSION Linear EUS is safe and effective for distinguishing the nature of the anastomotic stricture, and should be performed before endoscopic or surgical treatment.
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Affiliation(s)
- Sheng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shupeng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Wen Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Siyu Sun
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiang Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Nan Ge
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jintao Guo
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Guoxin Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Linlin Feng
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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9
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van Boeckel PGA, Siersema PD. Refractory esophageal strictures: what to do when dilation fails. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:47-58. [PMID: 25647687 PMCID: PMC4328110 DOI: 10.1007/s11938-014-0043-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, HP: F02.618, University Medical Center, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands,
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10
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Manfredi MA, Jennings RW, Anjum MW, Hamilton TE, Smithers CJ, Lightdale JR. Externally removable stents in the treatment of benign recalcitrant strictures and esophageal perforations in pediatric patients with esophageal atresia. Gastrointest Endosc 2014; 80:246-52. [PMID: 24650853 DOI: 10.1016/j.gie.2014.01.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/17/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND We investigated whether removable stents, such as self-expandable plastic stents (SEPSs) and fully covered self-expandable metal stents (FCSEMSs) could provide an alternative treatment for recalcitrant strictures and esophageal perforations after esophageal atresia (EA) repair. OBJECTIVE The primary aim of our study was to evaluate technical feasibility. Secondary aims were to evaluate safety and procedural success. DESIGN Retrospective study. SETTING Tertiary-care referral center. PATIENTS A total of 24 children with EA. INTERVENTIONS Retrospective review of all children with EA who underwent dilation and esophageal stent placement from January 2010 to February 2013 at our institution. MAIN OUTCOME MEASUREMENTS Healing of perforation and stricture resolution at 30 and 90 days. RESULTS A total of 41 stents (SEPSs 14, FCSEMSs 27) were placed in 24 patients with EA during the study period, including 14 who had developed esophageal leaks. Procedural success of esophageal stent placement in the treatment of refractory strictures was 39% at 30 days and 26% at 90 days. The success rate was 80% for closure of esophageal perforations with stent therapy after dilation and 25% for perforations associated with surgical repair. Adverse events of stent placement included migration (21% of SEPSs and 7% of FCSEMSs), granulation tissue (37% of FCSEMSs), and deep ulcerations (22% of FCSEMSs). LIMITATIONS Retrospective study with small sample size. CONCLUSION SEPSs and FCSEMSs can be placed successfully in small infants and children with a history of EA repair. The stents appear to be safe and beneficial in closing esophageal perforations, especially post-dilation. However, a high stricture recurrence rate after stent removal may limit their usefulness in treating recalcitrant esophageal anastomotic strictures.
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Affiliation(s)
- Michael A Manfredi
- Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA; Esophageal Atresia Treatment Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Esophageal Atresia Treatment Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - M Waseem Anjum
- Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Esophageal Atresia Treatment Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Esophageal Atresia Treatment Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jenifer R Lightdale
- Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
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11
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Fully covered self-expanding metal stents are effective for benign esophagogastric disruptions and strictures. J Gastrointest Surg 2013; 17:2045-50. [PMID: 24065368 DOI: 10.1007/s11605-013-2357-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/06/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE Self-expanding fully covered metal stents (CSs) are ideal for use in benign esophagogastric disease. We reviewed our experience with CS to evaluate outcomes, to determine a role for CS in a standard treatment for benign esophageal conditions, and to compare our results with recently published studies. METHODS We performed a retrospective chart review from 2005 to 2012. RESULTS A total of 57 CSs were placed in 44 patients. Indications were stricture (11 patients), anastomotic leak (20), perforation (7), and tracheoesophageal fistulae (6). For GI tract disruptions, open repair or diversion was avoided in 31/33 patients (93.9 %) but required an associated drainage procedure in 22/33 (67 %) patients. Resolution does not depend on achieving radiological control with 6/26 (23 %) having evidence of a persistent leak. Benign strictures were dilated at a mean of 3.7 times prior to stenting. Adjunctive intra-mucosal steroid injections were used in 8/11 patients. Stents were removed at a mean of 33 days. At a mean of 283 days of follow-up, 6/11 (54.5 %) had symptom resolution. The most common complication was stent migration occurring in 17.5 % of patients overall. CONCLUSION Covered stents are an effective adjunct in the management of benign upper gastrointestinal tract fistulae, leaks, perforations and benign strictures.
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12
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Jee SR, Cho JY, Kim KH, Kim SG, Cho JH. Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy. Clin Endosc 2013; 46:342-354. [PMID: 23964331 PMCID: PMC3746139 DOI: 10.5946/ce.2013.46.4.342] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 12/16/2022] Open
Abstract
Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.
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Affiliation(s)
- Sam Ryong Jee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joo Young Cho
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyung Ho Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jun-Hyung Cho
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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13
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Zeng Y, Dai YM, Wan XJ. Clinical remission following endoscopic placement of retrievable, fully covered metal stents in patients with esophageal achalasia. Dis Esophagus 2013; 27:103-8. [PMID: 23796127 DOI: 10.1111/dote.12083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty-nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0-10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post-therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post-therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post-therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.
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Affiliation(s)
- Y Zeng
- Department of Gastroenterology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiaog Tong University, Shanghai, China
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Karakan T, Utku OG, Dorukoz O, Sen I, Colak B, Erdal H, Karatay E, Tahtaci M, Cengiz M. Biodegradable stents for caustic esophageal strictures: a new therapeutic approach. Dis Esophagus 2013; 26:319-322. [PMID: 22974043 DOI: 10.1111/j.1442-2050.2012.01418.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The treatment of caustic esophageal strictures is a challenging topic. Although traditional therapies have limited efficacy, most of these patients eventually require surgery. Biodegradable (BD) stents are newly designed stents for benign conditions. This is a retrospective case series of seven patients with caustic esophageal stricture. BD esophageal stents were inserted for palliation of dysphagia. The position of the stent was checked at 1, 4, 8, 12 16, 20, and 24 weeks and at the end of follow-up period. The follow-up period was 60 ± 23 (36-102) weeks. Complete dissolution of the stent occurred at 16 ± 4 (12-20) weeks. Three patients had partial/complete relief of dysphagia. The remaining four patients experienced tissue hyperplasia at the edges of the stent and required serial dilations. At the end of follow-up, all patients had partial or complete relief of dysphagia. Although BD stents have some efficiency, tissue hyperplasia is the main limiting factor. Further randomized trials are needed to determine efficiency of BD stents for caustic damage.
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Affiliation(s)
- T Karakan
- Department of Gastroenterology, Gazi University, Ankara, Turkey.
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15
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Hirdes MMC, Vleggaar FP, Siersema PD. Stent placement for esophageal strictures: an update. Expert Rev Med Devices 2012; 8:733-55. [PMID: 22029470 DOI: 10.1586/erd.11.44] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.
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16
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Mullen TD, Sharma AK, Varma AK. Cervical osteomyelitis after placement of a self-expanding plastic stent for palliation of dysphagia associated with chemoradiation-induced esophageal strictures. Head Neck 2012; 35:E197-201. [PMID: 22367919 DOI: 10.1002/hed.22975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Esophageal strictures are a common sequela of chemoradiation and/or surgery to the head and neck cancers and can lead to stenosis and significant dysphagia. Endoscopic dilation endoscopic and placement of self-expanding stents are often to used relieve dysphagia symptoms. However, these stents are not without risks and complications. METHODS We present a case of a 58-year-old man who had the rare complication of cervical osteomyelitis as a result of plastic esophageal stent placement for palliation of chemoradiation-induced strictures. RESULTS The patient was successfully managed with immobilization of the cervical spine in a halo vest and appropriate antibiotics. CONCLUSION To the best of our knowledge, this is the first reported case of cervical spine osteomyelitis after self-expanding plastic stent (SEPS) placement for esophageal stricture. It was successfully treated with immobilization and antibiotic therapy. The treating physician should be aware of this rare complication to make an early diagnosis. Literature on esophageal stent-induced cervical osteomyelitis is reviewed.
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Affiliation(s)
- Thomas D Mullen
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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18
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van Heel NCM, Haringsma J, Wijnhoven BPL, Kuipers EJ. Endoscopic removal of self-expandable metal stents from the esophagus (with video). Gastrointest Endosc 2011; 74:44-50. [PMID: 21549376 DOI: 10.1016/j.gie.2011.02.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 02/25/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metals stents (SEMSs) have increasingly been used as a temporary device to bridge chemoradiotherapy in patients with malignant esophageal disease or in patients with benign esophageal defects or stenosis. OBJECTIVE To evaluate the outcome of removal of SEMSs in a large cohort of patients with benign and malignant esophageal disease. DESIGN Observational study with standardized treatment and follow-up. SETTING Single university center. PATIENTS Between 2001 and 2010, 95 consecutive patients referred for endoscopic SEMS extraction were included. INTERVENTIONS Endoscopic stent removal. MAIN OUTCOME MEASUREMENTS Technical and functional outcome and complications. RESULTS A total of 124 stent extractions were undertaken in 95 patients; both partially covered (68%) and fully covered (32%) SEMSs were removed. Three patients had 2 overlapping SEMSs in place. Successful primary removal was achieved in 89%; the secondary removal rate was 96%. Uncomplicated primary removal rate was significantly higher for fully covered versus partially covered stents (P = .035) and for single versus overlapping stents (P = .033). Patients with a complicated stent removal had the stent in place significantly longer compared with patients with an uncomplicated primary stent removal (126 days vs 28 days; P = .01). Surgical removal was required in 3 patients (2.4%). Six moderate and severe complications (5%) related to the endoscopic extraction occurred. LIMITATIONS Retrospective, nonrandomized study design. CONCLUSIONS Primary endoscopic removal of an SEMS is feasible in the majority of patients with benign and malignant esophageal disease. A longer time that a stent is in place and the use of partially covered SEMSs both impede removal. Moreover, overlapping SEMSs should be avoided for temporary use because stent disintegration and subsequent complications may occur.
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Affiliation(s)
- Nicoline C M van Heel
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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19
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Matsumoto S, Miyatani H, Yoshida Y, Nokubi M. Cicatricial stenosis after endoscopic submucosal dissection of esophageal cancer effectively treated with a temporary self-expandable metal stent. Gastrointest Endosc 2011; 73:1309-1312. [PMID: 21272877 DOI: 10.1016/j.gie.2010.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/04/2010] [Indexed: 12/31/2022]
Affiliation(s)
- Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Omiya, Saitama, Japan
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20
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Cheon YK. Metal stenting to resolve post-photodynamic therapy stricture in early esophageal cancer. World J Gastroenterol 2011; 17:1379-82. [PMID: 21455341 PMCID: PMC3068277 DOI: 10.3748/wjg.v17.i10.1379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Photodynamic therapy (PDT) is an established endoscopic technique for ablating Barrett’s esophagus with high-grade dysplasia or early-stage intraepithelial neoplasia. The most common clinically significant adverse effect of PDT is esophageal stricture formation. The strictures are usually superficial and might be dilated effectively with standard endoscopic accessories, such as endoscope balloon or Savary dilators. However, multiple dilations might be required to achieve stricture resolution in some cases. We report the case of stricture that recurred after dilation with a bougie, which was completely relieved by a self-expandable metal stent.
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Repici A, Vleggaar FP, Hassan C, van Boeckel PG, Romeo F, Pagano N, Malesci A, Siersema PD. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72:927-34. [PMID: 21034894 DOI: 10.1016/j.gie.2010.07.031] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/21/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Benign esophageal strictures refractory to standard dilation therapy present a challenging problem. Temporary plastic and metal stents have been proposed with inconclusive results. OBJECTIVE To evaluate the efficacy and safety of a new biodegradable stent for the treatment of refractory benign esophageal strictures (RBESs). DESIGN AND SETTING Prospective study from 2 European endoscopy centers. PATIENTS AND INTERVENTION Twenty-one patients (11 men/10 women, mean age 60.2 ± 17.6 years) with RBESs defined according to the Kochman criteria treated by placement of a biodegradable stent (Ella stent). MAIN OUTCOME MEASUREMENTS Clinical and endoscopic follow-up was scheduled at 1, 2, 3, and 6 months and later only in case of dysphagia recurrence. Pre- and poststenting dysphagia status was graded according to a 5-point scale. Minor and major complication rates were prospectively assessed. RESULTS Stent insertion was technically successful in all of the patients. At 4 and 7 weeks, stent migration occurred in 2 patients (9.5%). At 3-month endoscopy, the stent appeared to be almost completely fragmented in all remaining patients. The median pre- and poststenting dysphagia scores were 3 (range 3-4) and 1 (range 0-2), respectively (P < .01), with a median follow-up of 53 weeks (range 25-88 weeks). In detail, 9 of 20 patients (45%) were dysphagia free at the end of the follow-up. No major complications occurred. Severe poststenting pain requiring analgesics developed in 3 patients, and minor bleeding was observed in 1 patient. LIMITATIONS Limited follow-up; nonrandomized study. CONCLUSIONS In this preliminary study, the biodegradable stent showed a favorable risk/benefit ratio, achieving complete relief of dysphagia in nearly 50% of RBES patients without the occurrence of major complications. The use of this stent may be a valuable alternative to repeat endoscopic dilation. Larger studies with longer follow-up are needed.
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Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy.
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22
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Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 2010; 89:931-6; discussion 936-7. [PMID: 20172156 DOI: 10.1016/j.athoracsur.2009.10.061] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 10/26/2009] [Accepted: 10/28/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Esophageal or gastric leakage from anastomotic wound dehiscence, perforation, staple line dehiscence, or trauma can be a devastating event. Traditional therapy has often consisted of either surgical repair for rapidly diagnosed leaks or diversion for more complicated cases, commonly associated with a delayed diagnosis. This study summarizes our experience treating leaks or fistulas with novel, covered self-expanding metal stents (cSEMS). The primary objective of this study was to determine the efficacy and safety of covered self-expanding metal stents when used to treat complicated leaks and fistulas. METHODS Over 15 months, 25 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment. A prospective database was used to collect data. Stents were placed endoscopically, with contrast evaluation used for leak evaluation. Patients who did not improve clinically after stenting or whose leak could not be sealed underwent operative management. RESULTS During a mean follow-up of 15 months, 23 of the 25 patients with esophageal or gastric leaks during a 15-month period were managed with endoscopic stenting as primary treatment. Healing occurred in patients who were stented for anastomotic leakage after gastric bypass or sleeve gastrectomy (n = 10). One patient with three esophageal iatrogenic perforations healed with stenting. Eight patients successfully avoided esophageal diversion and healed with stenting and adjunctive therapy. Two of the 4 patients with tracheoesophageal fistulas sealed with the assistance of a new pexy technique to prevent stent migration; 1 additional patient had this same technique used to successfully heal an upper esophageal perforation. CONCLUSIONS Esophageal leaks and fistulas can be effectively managed with cSEMS as a primary modality. The potential benefits of esophageal stenting are healing without diversion or reconstruction and early return to an oral diet.
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Affiliation(s)
- Shanda H Blackmon
- Department of Surgery, The Methodist Hospital, Houston, Texas 77030, USA.
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23
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Kochhar R, Poornachandra KS. Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc 2010; 2:61-8. [PMID: 21160692 PMCID: PMC2999060 DOI: 10.4253/wjge.v2.i2.61] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Revised: 09/07/2009] [Accepted: 09/15/2009] [Indexed: 02/05/2023] Open
Abstract
Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.
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Affiliation(s)
- Rakesh Kochhar
- Rakesh Kochhar, Kuchhangi Suresh Poornachandra, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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24
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Abstract
These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.
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Affiliation(s)
- Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA.
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25
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Siersema PD, de Wijkerslooth LRH. Dilation of refractory benign esophageal strictures. Gastrointest Endosc 2009; 70:1000-12. [PMID: 19879408 DOI: 10.1016/j.gie.2009.07.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 07/03/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Peter D Siersema
- Department of Gastroenterology & Hepatology, University Medical Center, Utrecht, The Netherlands
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26
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Abstract
It is challenging to manage benign refractory esophageal strictures. We have now moved on from instant dilators to prolonged gradual dilatations using expandable stents that can be removed or biodegradable after a period of time left in situ. Recent published experience and the present study by Dua et al. have demonstrated the feasibility of this technique. However, not all strictures are the same and several issues need to be addressed including stent migration, stent duration, and the sub-group of patients who will benefit most.
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Abstract
Esophageal stents were used initially in the palliative treatment of esophageal carcinoma to improve the life quality of the patients in the advanced stage. Along with the appearance of many new kinds of esophageal stents, esophageal stents have been used in the management of the benign esophageal strictures, and clinical effectiveness has been made. This article reviews the application of the esophageal stents in the benign and malignant esophageal strictures.
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28
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Self-Expanding Stents in Benign Esophageal Strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Kim AW, Liptay MJ, Snow N, Donahue P, Warren WH. Utility of Silicone Esophageal Bypass Stents in the Management of Delayed Complex Esophageal Disruptions. Ann Thorac Surg 2008; 85:1962-7; discussion 1967. [DOI: 10.1016/j.athoracsur.2008.02.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 02/12/2008] [Accepted: 02/13/2008] [Indexed: 11/29/2022]
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Marjanovic G, Schrag HJ, Fischer E, Hopt UT, Fischer A. Endoscopic bougienage of benign anastomotic strictures in patients after esophageal resection: the effect of the extent of stricture on bougienage results. Dis Esophagus 2008; 21:551-7. [PMID: 18430180 DOI: 10.1111/j.1442-2050.2008.00819.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of our retrospective study was to determine the incidence of benign anastomotic strictures (BAS) in patients after esophageal resection and to examine the influence of the extent of BAS on the results of bougienage therapy. From January 2001 to July 2006, 79 patients at risk of BAS development were included in the study. BAS was diagnosed with a median delay of 8 weeks (4-26) postoperative in 23 patients (29%). A median of 4 bougienage sessions (2-20) was needed for success (success rate 100%). The mean follow-up time was 22 months [range 3-47]. There were no late recurrences of BAS. Five patients had an anastomosis diameter <5.5 mm and 14 patients >5.5 mm. There was no difference in median number of bougienage procedures in these subgroups (4.5 [2-9] vs. 4 [2-20]). Patients who presented with BAS earlier than 6 weeks postoperative had more procedures (median 8 [2-20] vs. 4 [2-9]) than those presenting later. Patients in whom first bougienage was possible to only 16 mm diameter needed more procedures than patients in whom first dilation was possible to more than 16 mm (median 5.5 [3-20] vs. 3 [2-9]). In conclusion, both early BAS development and the diameter of bougienage at first endoscopy, but not the extent of stricture, seem to be predictive factors for longer bougienage therapy. In order to influence the BAS formation early, we now routinely examine every patient after esophageal resection endoscopically in the 6th postoperative week.
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Affiliation(s)
- G Marjanovic
- Department of General and Visceral Surgery, University Hospital of Freiburg, Freiburg, Germany.
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31
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Siersema PD. Treatment options for esophageal strictures. ACTA ACUST UNITED AC 2008; 5:142-52. [PMID: 18250638 DOI: 10.1038/ncpgasthep1053] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 12/10/2007] [Indexed: 01/10/2023]
Abstract
Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.
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Affiliation(s)
- Peter D Siersema
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Wong RF, Adler DG, Hilden K, Fang JC. Retrievable esophageal stents for benign indications. Dig Dis Sci 2008; 53:322-9. [PMID: 17597404 DOI: 10.1007/s10620-007-9883-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 05/14/2007] [Indexed: 12/30/2022]
Abstract
Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.
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Affiliation(s)
- Robert F Wong
- University of Utah School of Medicine, 30 North 1900 East, 4R118 School of Medicine, Salt Lake City, UT 84132, USA.
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Velasco A, Alvarez A, Prieto V, Geijo F, Pordomingo A, Fradejas P, Rodriguez A, Rodriguez MT. Refractory benign esophageal stricture. Am J Gastroenterol 2007; 102:2110-1. [PMID: 17727446 DOI: 10.1111/j.1572-0241.2007.01324_10.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Solt J, Sarlós G, Tabár B, Bertalan A. Treatment of large, oesophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage. Orv Hetil 2007; 148:1601-7. [PMID: 17702689 DOI: 10.1556/oh.2007.28053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A bevont fémstentek benignus nyelőcső-stenosisban és -perforatioban való alkalmazása, a stent okozta szöveti reakció és a stent eltávolítás nehézségei miatt, kezdeti stádiumban van. A szerzők nyelőcső-perforatioban egy újabb, bevont fémstent terápiás hatását és eltávolítására kidolgozott módszerük hatékonyságát vizsgálták 3 beteg kapcsán. Három beteg közül kettőnél corrosiv nyelőcsőstenosis tágításakor perforatio lépett fel. Emiatt az egyiknél mediastinalis drenázs és jejunostomia, másiknál primér sutura és drenázs történt. Ezt követően mindkettőben septicus állapot, mediastinitis alakult ki. Ennek hátterében egyiknél perforatio mellett mediastinalis drén okozta nyelőcsőfistula, a másiknál nyelőcsővarrat-elégtelenség állt. A nyelőcső falának defektusát 8, illetve 10 nappal a perforatio, műtét után bevont fémstenttel hidalták át. A harmadik beteg inoperabilis nyelőcsőtumora okozta stenosisának tágítása, stentelési kísérlete során nyelőcsőruptura lépett fel, melyet két órán belül bevont fémstenttel zárta. Parenteralis táplálást, széles spectrumú antibioticus kezelést alkalmaztak. Három nap múlva ellenőrizve mindhárom stent tölcsére tökéletesen zárt. Nasogastricus szonda-, majd per os táplálásra tértek át. Átmeneti mediastinalis drenázs után a stenteket 35, illetve 74 nappal a stentimplantatio után endoscoposan távolították el. Ez idő alatt a nyelőcsőfal-defectusok, a perforatios nyílások záródtak. A stent felső szélénél jelentkező stenosist mindkét betegnél tágították. A 3. betegnél a tumoros nyelőcsőruptura korai, végleges stentelése után szövődmény nem lépett fel. Itt drenázsra nem volt szükség. Nagy nyelőcső-perforatio – kísérő septicus állapot, mediastinitis esetén is – sikeresen gyógyítható bevont, eltávolítható fémstenttel és megfelelő mediastinalis drenázzsal.
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Affiliation(s)
- Jeno Solt
- Baranya Megyei Kórház Gasztroenterológiai Osztály, Pécs.
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Conio M, Blanchi S, Filiberti R, Repici A, Barbieri M, Bilardi C, Siersema PD. A modified self-expanding Niti-S stent for the management of benign hypopharyngeal strictures. Gastrointest Endosc 2007; 65:714-20. [PMID: 17383472 DOI: 10.1016/j.gie.2007.02.050] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The management of patients with refractory hypopharyngeal strictures after surgery in combination with radiation therapy is disappointing, and nutrition through feeding tubes is often required. OBJECTIVE To evaluate the efficacy and safety of a modified self-expanding Niti-S metal stent in the treatment of hypopharyngeal strictures after combined therapy for laryngeal cancer. DESIGN Case series. SETTING A general hospital and a university hospital. PATIENTS Seven consecutive patients were included. One of them did not have laryngectomy. INTERVENTIONS All patients received a modified Niti-S stent. MAIN OUTCOME MEASUREMENTS Improvement of dysphagia, avoiding periodic bougienage, and enteral nutrition through feeding tubes. RESULTS After placement of the first stent, dysphagia improved in all patients. Six of 7 patients developed stent migration and/or granulomatous tissue ingrowth or overgrowth. Additional stents were placed in all patients after a median of 3 months after the previous stent placement. One patient developed an esophagorespiratory fistula caused by a Polyflex stent. Two patients died of causes unrelated to the stent. The remaining 5 patients remained alive and asymptomatic after a median follow-up of 10 months. LIMITATIONS Periodic stent exchange. Stent placement did not resolve the stricture definitively. We had a limited number of patients and have no long-term outcome data yet. CONCLUSIONS The use of this modified Niti-S stent avoids both enteral nutrition through feeding tubes and the need for periodic bougienage in patients with difficult-to-treat benign hypopharyngeal strictures.
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Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy
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36
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Choi EK, Song HY, Shin JH, Kim JW. Removal of a Covered Esophageal Metallic Stent 8 Years after Placement. J Vasc Interv Radiol 2007; 18:317-20. [PMID: 17327569 DOI: 10.1016/j.jvir.2006.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
A covered expandable esophageal metallic stent was placed to treat a corrosive esophageal stricture that was refractory to repeated balloon dilations. The stent was removed 8 years after placement due to severe dysphagia. The stented esophageal area has since maintained long-term patency for 2 years. These results suggest the feasibility of removal of a metallic stent after long-term stent placement.
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Affiliation(s)
- Eugene K Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, Republic of Korea
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37
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Seo YS, Park JJ, Kim BG, Kim JH, Kim JH, Kim CH, Kim JY, Byun KS, Bak YT. Segmental amputation of esophagus with bronchial-wall rupture during removal of a stent for benign esophageal stricture. Gastrointest Endosc 2006; 64:141-3. [PMID: 16813827 DOI: 10.1016/j.gie.2006.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 02/06/2006] [Indexed: 12/31/2022]
Affiliation(s)
- Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Gurodong-gil 97, Guro-go, Seoul 152-703, Korea
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Endoscopic Treatment of Luminal Anastomotic Strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2006. [DOI: 10.1016/j.tgie.2006.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Shah JN. Benign refractory esophageal strictures: widening the endoscopist's role. Gastrointest Endosc 2006; 63:164-7. [PMID: 16377341 DOI: 10.1016/j.gie.2005.08.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Accepted: 08/29/2005] [Indexed: 12/10/2022]
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40
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Kochman ML, McClave SA, Boyce HW. The refractory and the recurrent esophageal stricture: a definition. Gastrointest Endosc 2005; 62:474-5. [PMID: 16111985 DOI: 10.1016/j.gie.2005.04.050] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 04/29/2005] [Indexed: 02/07/2023]
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41
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Affiliation(s)
- David Mitton
- Department of Surgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
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42
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Yoon CJ, Shin JH, Song HY, Lim JO, Yoon HK, Sung KB. Removal of retrievable esophageal and gastrointestinal stents: experience in 113 patients. AJR Am J Roentgenol 2004; 183:1437-44. [PMID: 15505317 DOI: 10.2214/ajr.183.5.1831437] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Although there are frequent clinical situations in which esophageal and gastrointestinal stents should be removed, nonsurgical stent removal has been difficult. The purpose of our study was to describe the safety and efficacy of removing the retrievable nitinol stents with a retrieval hook. MATERIALS AND METHODS Under fluoroscopic guidance, the removal of 119 esophageal, six gastroduodenal, and five rectal retrievable stents was attempted in 113 patients using a retrieval hook. Indications for stent removal included migration (n = 35), severe pain (n = 23), formation of a new stricture (n = 13), incomplete stent expansion (n = 7), airway compression (n = 2), esophagorespiratory fistula (n = 2), malpositioned stent (n = 1), and hematemesis (n = 1). The remaining 46 stents were electively removed. RESULTS Of the 130 stents, 127 (97.7%) were successfully removed despite the following difficulties: untied drawstrings (n = 4), separation of the stent (n = 3), and fracture (n = 2) or disconnection (n = 2) of a retrieval hook. The removal procedure failed in three cases (2.3%). The causes of failure were the inability to place the hook into the migrated stent (n = 2) and a tight stricture above the migrated stent (n = 1). The procedure-related complications included minor (n = 4) and major (n = 1) bleeding and intramural rupture (n = 3). One patient died of major bleeding after removal of an esophageal stent. CONCLUSION The stent retrieval hook is useful for removing retrievable esophageal and gastrointestinal stents.
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Affiliation(s)
- Chang Jin Yoon
- Department of Radiology, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, South Korea
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43
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Pungpapong S, Raimondo M, Wallace MB, Woodward TA. Problematic esophageal stricture: an emerging indication for self-expandable silicone stents. Gastrointest Endosc 2004; 60:842-5. [PMID: 15557974 DOI: 10.1016/s0016-5107(04)02035-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Surakit Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Jacksonville, Florida 32224, USA
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Abstract
Peptic esophageal stricture (PES) is a major complication of gastroesophageal reflux disease. The aims of this paper were to determine the characteristics of these patients with regard to demography, morphology, functional status and results of therapy. The charts of the patients treated at our service who underwent esophageal dilatation for PES between 1971 and 1998 were reviewed. Statistical analyses were performed by means of chi2, Mann-Whitney and Student's t-tests. One hundred and thirty-five patients with PES were dilated by various means. The mean age was 61.1 +/- 16.3 years, the ratio of men to women was 2.75/1 and mean duration of symptoms was 44.4 +/- 74.6 months. Their symptoms were dysphagia in 100%, pyrosis in 70%, and regurgitation in 40% of the cases. There was an average weight loss of 3.3 +/- 6 kg. The upper gastro-intestinal series showed pre- and post-dilatation diameters at the stricture of 8 +/- 2.5 mm and 15.9 +/- 1.2 mm, respectively. The stricture was located at the lower third of the esophagus in 97% and at the middle third in 3% of the cases. We found PES endoscopically in all instances, with different degrees of erosions in 64%, ulcers in 20% and Barrett's esophagus in 16% of the cases. The biopsy samples showed intestinal metaplasia in 16% and esophagitis in 75.5%, being normal in the remaining 8.5%. Brush cytology was negative for malignancy in 100% of the cases. Esophageal manometry showed peristaltic wave amplitude of 40 +/- 3 mmHg and presence of peristaltic waves of 62 +/- 38.6%. LES pressure was 8.6 +/- 6.3 mmHg (NV 24.2 +/- 6.3 mmHg). Measurement of pH showed 15% of patients had pH < 4. Patients needed a mean of 4.7 +/- 1.6 dilations per case, with successful results in 87.2% of cases. The perforation rate was 0.1% of the total number of procedures and 0.7%, of patients. The mortality rate was 0.7% (one case). We observed PES relapse in 32% of the cases. There was no correlation between relapse, age, duration of the stenosis or pharmacological treatment with H2 blockers or proton pump inhibitors. We conclude that in Argentina, demography, morphology, functional status and results of dilatation of PES patients are similar to those reported in the Western world, with the exception of the different behavior seen after treatment with H2 blockers or proton pump inhibitors.
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Affiliation(s)
- Sergio Angel Mazzadi
- Gastroenterology Service, Hospital Profesor Alejandro Posadas, Palomar City, Argentina
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45
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Cheng YS, Li MH, Chen WX, Zhuang QX, Chen NW, Shang KZ. Follow-up evaluation for benign stricture of upper gastrointestinal tract with stent insertion. World J Gastroenterol 2003; 9:2609-2611. [PMID: 14606108 PMCID: PMC4656552 DOI: 10.3748/wjg.v9.i11.2609] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2003] [Revised: 05/23/2003] [Accepted: 06/02/2003] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the best method for benign stricture of the upper gastrointestinal tract (UGIT) with stent insertion by follow-up evaluation. METHODS A total of 110 stents insertions were performed in 110 cases of benign stricture of the UGIT. Permanent (group A) and temporary (group B) placement of an expandable metal stent in 30 cases and 80 cases respectively. All cases were completed under fluoroscopy. RESULTS In group A, 30 uncovered or antireflux covered or partially covered expandable metal stents were placed permanently. In group A, 5 cases (16.7%) in 3-months, 5 cases (20.0%) in 6-months, 6 cases (25%) in the 1st year, 6 cases (50%) in the 3rd year, and 4 cases (80%) in the 5th year exhibited dysphagia relapse. In group B, a partially-covered expandable metal stent was temporarily placed in each patient and removed after 3-7 days via gastroscopy. Follow-up data in this group showed that 8 cases (7.5%) in 3-months, 9 cases (12.0%) in 6-months, 10 cases (15.4%) in the 1st year, 6 cases (20%) in the 3rd year, and 3 cases (25%) in the 5th year exhibited dysphagia relapse. The placement and withdrawal of all stents were all performed successfully. The follow-up of all cases lasted for 3-99 months (mean 41.6+/-19.7 months). CONCLUSION The best method for benign stricture of UGIT with stent insertion is temporary placement of a partially-covered expandable metal stent.
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Affiliation(s)
- Ying-Sheng Cheng
- Department of Radiology, Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, China.
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46
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Vasilopoulos S, Shaker R. Defiant dysphagia: small-caliber esophagus and refractory benign esophageal strictures. Curr Gastroenterol Rep 2003; 3:225-30. [PMID: 11353559 DOI: 10.1007/s11894-001-0026-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Among causes of defiant dysphagia, two pose a special challenge for the clinician: the small-caliber esophagus and refractory benign esophageal strictures. The small-caliber esophagus is a major cause of dysphagia for solids in young patients with eosinophilic esophagitis. A smooth, diffusely narrow esophageal lumen can be appreciated by barium esophagography or esophagoscopy. The term "small-caliber esophagus" is preferred over "stricture" because of the absence of cicatrization. A "subtle" small-caliber esophagus may defy detection by barium esophagogram and esophagogastroduodenoscopy. The only evidence to its diagnosis is the endoscopic finding of unusually long rents in the body of the esophagus immediately after esophageal dilation. The ringed esophagus seems to be a variant of the small-caliber esophagus, with the additional endoscopic finding of a variable number of rings (few to numerous) throughout the narrowed esophagus. Classification, diagnosis, and management of small-caliber esophagus are discussed in this review. Refractory esophageal strictures have various causes, including gastroesophageal reflux disease, nasogastric tube placement, mediastinal irradiation, and corrosive ingestion. Treatments used to eliminate or reduce the need for frequent esophageal bougienage include acid-suppressive medical therapy, surgery, intralesional corticosteroid injection, and esophageal self-expandable metal stents.
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Affiliation(s)
- S Vasilopoulos
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin Dysphagia Institute, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Rodriguez-Baez N, Andersen JM. Management of Esophageal Strictures in Children. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:417-425. [PMID: 12954148 DOI: 10.1007/s11938-003-0044-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Esophageal dilatation remains the primary treatment of esophageal strictures. Aggressive esophageal dilatation is indicated regardless of the etiology and length of the stricture. Esophageal dilatation causes iatrogenic trauma and tearing of scar tissue that may result in restricturing. Local infiltration of triamcinolone into the stricture site at the time of dilatation may markedly reduce subsequent scar formation and restricturing. Intralesional triamcinolone is most useful for short strictures and may decrease the need for future dilatation. Successful management of esophageal strictures requires the aggressive treatment of all pathogenic processes contributing to esophageal inflammation and restricturing following dilatation. Medically uncontrolled reflux esophagitis may require antireflux surgery to successfully dilate the stricture. Balloon dilators apply only radial forces and no longitudinal, shearing forces. They are most useful for two situations: circumstances under which it is desirable to minimize esophageal trauma (eg, epidermolysis bullosa) and short strictures. Savary-Gilliard dilators are useful for strictures resistant to balloon dilatation and for long strictures that require carefully controlled and graded dilatation. We routinely use dilators instead of guide wires for long strictures, multiple strictures, tortuous esophagus, and very narrow strictures, particularly when the state of the esophagus distal to the stricture is unclear. Failure of aggressive, frequent dilatation to maintain sufficient esophageal luminal diameter may necessitate surgical intervention (ie, resection of the stricture or esophageal replacement).
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Affiliation(s)
- Norberto Rodriguez-Baez
- Department of Gastroenterology and Nutrition, University of Texas Southwestern Medical School, 1935 Motor Street, Dallas, TX 75235, USA
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48
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Cheng YS, Li MH, Chen WX, Chen NW, Zhuang QX, Shang KZ. Temporary partially-covered metal stent insertion in benign esophageal stricture. World J Gastroenterol 2003; 9:2359-2361. [PMID: 14562413 PMCID: PMC4656498 DOI: 10.3748/wjg.v9.i10.2359] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2003] [Revised: 05/25/2003] [Accepted: 06/02/2003] [Indexed: 02/06/2023] Open
Abstract
AIM To study the therapeutic efficacy of temporary partially-covered metal stent insertion on benign esophageal stricture. METHODS Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores. RESULTS Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20+/-0.63 (mean+/-SD) and 0.68+/-0.31 before and after stent insertion, and 0.86+/-0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37+/-1.23 mm and 25.77+/-3.89 mm before and after stent insertion, and 16.15+/-2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26+/-12.75 months). The complications were chest pain (n=37) after stent insertion, and bleeding (n=12) and reflux (n=13) after stent removal. CONCLUSION Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.
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Affiliation(s)
- Ying-Sheng Cheng
- Department of Radiology, Sixth People's Hospital, Shanghai Jiaotong University, Shanghai 200233, China.
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49
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Schubert D, Kuhn R, Lippert H, Pross M. Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with diathermy. Surg Endosc 2003; 17:1579-82. [PMID: 12874683 DOI: 10.1007/s00464-002-9173-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2002] [Accepted: 03/18/2003] [Indexed: 12/18/2022]
Abstract
BACKGROUND Initially, treatment for anastomotic strictures was surgical. Currently. however, endoscopic techniques are preferred. This study aimed to investigate the efficiency and safety of endoscopic treatment using argon plasma coagulation in combination with diathermy. METHODS From 1995 to 2000, 49 patients with postsurgical anastomotic strictures of the esophagus or colon were referred for endoscopic treatment. In all cases, radiologic and endoscopic examination showed membranous or short strictures (diameter, 3-8 mm). Under direct endoscopic control, the scar tissue at the anastomotic line was incised radially with a polypectomy snare. The scar tissue between the incisions then was reduced carefully by argon plasma coagulation. RESULTS All 49 patients were treated successfully with this combined endoscopic technique. Only for four patients was more than one endoscopic session (mean, 3.5; range, 2-6) needed to guarantee long-term success. No complications were encountered. CONCLUSIONS Endoscopic argon plasma coagulation in combination with diathermy is a safe and effective technique for the treatment of short postsurgical gastrointestinal anastomotic strictures.
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Affiliation(s)
- D Schubert
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Otto von Guericke University Magdeburg, Leipziger Strasse 44, 39120 Magdeburg, Germany.
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Sampaio JA, Waechter FL, Pereira-Lima J, Fossati MAM, Felicetti JC, Thiesen VLP, Rostirolla RA, Marques DL, Hornos AP, Pereira-Lima L. Successful treatment of esophagojejunal disconnection after total gastrectomy by insertion of a covered self-expandable esophageal metallic stent. Gastrointest Endosc 2003; 58:453-6. [PMID: 14528230 DOI: 10.1067/s0016-5107(03)00030-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- José Artur Sampaio
- Departments of Surgery and Gastroenterology, Hospital Moinhos de Vento, Porto Alegre, Brazil
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