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Management of Adults With Esophageal Atresia. Clin Gastroenterol Hepatol 2023; 21:15-25. [PMID: 35952943 DOI: 10.1016/j.cgh.2022.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 02/07/2023]
Abstract
Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.
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Zhou B, Peng H, Han L, Liang C, Lv L, Wang X, Liu D, Tan Y. Endoscopic Treatment for Pediatric Esophageal Stenosis Induced by Chemical Burn, Congenitally, or After Surgical Repair of Esophageal Atresia. Front Pediatr 2022; 10:814901. [PMID: 35281238 PMCID: PMC8914068 DOI: 10.3389/fped.2022.814901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To evaluate the safety and efficacy of endoscopic treatment for congenital pediatric esophageal stenosis or pediatric stenosis that develops after a chemical burn or surgical repair of esophageal atresia. METHODS We retrospectively reviewed the medical records of 15 pediatric patients who underwent endoscopic treatments (dilation and/or stenting and/or incision) for congenital esophageal stenosis or esophageal stenosis that developed after a chemical burn or surgical repair of esophageal atresia, between January 2010 and January 2019. The patients were periodically followed-up to assess the safety and efficacy of treatment by comparing the diameter of stricture and dysphagia score before and after procedures, and complications or recurrence. RESULTS All children successfully underwent the procedures. Fourteen of the 15 patients received endoscopic balloon dilation (EBD) as the first step of treatment, but EBD alone only resolved the symptoms in two patients. The remaining patients received other comprehensive treatments, such as EBD with endoscopic incision (EI), EBD with stent replacement, or a combination of EBD, stent replacement, and EI. Eleven (11/15, 73.3%) patients experienced symptomatic relief after endoscopic treatment, and recurrence was noted in four patients on 3-36 months after the final endoscopic treatment. All four patients underwent esophageal surgery to relieve their symptoms. Until October 2021, all patients experienced symptom relief, and their dysphagia scores decreased from 3-4 to 0-1 during the follow-up period of 8-121 months. The average diameter of stenosis was increased from 0.34 cm (range 0.2-0.7 cm) to 1.03 cm (range 0.8-1.2 cm). No severe complications occurred during endoscopic treatment and follow-up. CONCLUSIONS Endoscopic treatment is safe and effective for pediatric esophageal stenosis that is congenital or induced by chemical burns or surgical repair of esophageal atresia. Comparative large-scale studies are required to confirm our findings.
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Affiliation(s)
- Bingyi Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Hailing Peng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liu Han
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
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van Hal ARL, Pulvirenti R, den Hartog FPJ, Vlot J. The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review. Front Pediatr 2021; 9:825030. [PMID: 35165653 PMCID: PMC8837747 DOI: 10.3389/fped.2021.825030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures. METHODS A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention. RESULTS The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3). CONCLUSION The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI. SYSTEMATIC REVIEW REGISTRATION PROSPERO, identifier: CRD42021281584.
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Affiliation(s)
- Annefleur R L van Hal
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
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Intralesional steroids and endoscopic dilation for anastomotic strictures after esophagectomy: systematic review and meta-analysis. Endoscopy 2020; 52:721-726. [PMID: 32450581 DOI: 10.1055/a-1172-5975] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-esophagectomy anastomotic strictures are difficult to treat. The impact of adding local steroid injection to endoscopic dilation for the treatment of post-esophagectomy anastomotic strictures is unclear. We conducted a systematic review and meta-analysis to assess the efficacy of performing steroid injection in addition to dilation. METHODS A search was conducted in MEDLINE, Cochrane Library, EMBASE, and Web of Science from inception to January 2019. Randomized controlled trials (RCTs) comparing the efficacy of endoscopic dilation plus either local steroid injection (steroid group) or saline injection (placebo group) were included in the analysis. RESULTS Three RCTs were eligible for the final analysis: 72 patients (mean age 61.3 years, 74 % male) in the steroid group and 72 patients (mean age 59.6 years, 71 % male) in the placebo group. The mean number of dilations required to resolve the stricture was significantly lower in the steroid group compared with the placebo group, with a mean weighted difference of -1.62 (95 % confidence interval [CI] -2.73 to -0.50; P = 0.004). After 6 months of follow-up, there was a trend toward more patients in the steroid group remaining dysphagia free compared with the placebo group, with a pooled odds ratio of 2.36 (95 %CI 0.94 to 5.91; P = 0.07, I2 = 24 %). CONCLUSION This meta-analysis showed that the addition of local steroid injection at the time of dilation for benign anastomotic strictures led to a significant decrease in the number of procedures required to resolve the stricture and may well reduce dysphagia symptoms during follow-up.
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Intralesional Steroid Injection Therapy for Esophageal Anastomotic Stricture Following Esophageal Atresia Repair. J Pediatr Gastroenterol Nutr 2020; 70:462-467. [PMID: 31764412 DOI: 10.1097/mpg.0000000000002562] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The role of intralesional steroid injection (ISI) in the treatment of anastomotic stricture in patients with esophageal atresia remains unclear. The aim of this study was to evaluate the efficacy and safety of ISI. METHODS A total of 158 patients with esophageal atresia with at least 1 ISI for the treatment of esophageal anastomotic stricture between 2010 and 2017 were identified. The change in stricture diameter (ΔD) was compared between procedures with dilation alone (ISI-) and dilation with steroid injection (ISI+). RESULTS A total of 1055 balloon dilations were performed (452 ISI+). The median ΔD was significantly greater in the ISI+ group: 1 mm (interquartile range [IQR] 0, 3) versus 0 mm (IQR -1, 1.5) (P < 0.0001). The ISI+ group had greater percentage of improved diameter (P < 0.0001) and lesser percentages of unchanged and decreased diameters at subsequent endoscopy (P = 0.0009, P = 0.003). Multivariable logistic regression confirmed the significance of ISI on increasing the likelihood of improved stricture diameter with an adjusted odds ratio of 3.24 (95% confidence interval: 2.15-4.88) (P < 0.001). The ΔD for the first 3 ISI+ procedures was greater than the ΔD for subsequent ISI+ procedures: 1 mm (IQR 0, 3) versus 0.5 mm (IQR-1.25, 2) (P = 0.001). There was no difference in perforation incidence between ISI+ and ISI- groups (P = 0.82). CONCLUSIONS ISI with dilation was well tolerated and improved anastomotic stricture diameter more than dilation alone. The benefit of ISI over dilation alone was limited to the first 3 ISI procedures.
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Ten Kate CA, Vlot J, Sloots CEJ, van den Akker ELT, Wijnen RMH. The effect of intralesional steroid injections on esophageal strictures and the child as whole: A case series. J Pediatr Surg 2020; 55:646-650. [PMID: 31196669 DOI: 10.1016/j.jpedsurg.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/12/2019] [Accepted: 05/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND The most frequent complication after esophageal atresia repair remains anastomotic stricture formation. The initial treatment is endoscopic dilatation. Intralesional steroid injection (ISI) might be an effective adjuvant treatment in case of recurrent strictures. In this series we present our initial experience with this intervention. METHODS Data on primary surgery, stricture treatment, postoperative complications, outcome and growth were retrospectively collected from electronic patient records. Findings were analyzed by descriptive statistics and mixed model analysis. RESULTS Between 2014 and 2017, ISI was performed for severe recurrent anastomotic strictures in six patients (median age at injection 12.4 (2.1-34.7) months) after a median of 6 (2-20) dilatations. In five patients ISI was successful and the stenosis was cleared. No postoperative complications were reported, especially none related to acute adrenal suppression. Comparing the year before with the year after ISI, a significant positive change for weight (r = 0.70, p = 0.003) was calculated versus a negative change for height (r = -0.87, p = 0.003). CONCLUSIONS We found ISI to be an effective adjuvant treatment to recurrent anastomotic stricture dilatation after esophageal atresia repair, without postoperative complications or symptoms of adrenal suppression. It remains important, however, to monitor growth effects. Further evaluation is required in a large prospective study. TYPE OF STUDY Treatment study, Level IV (case series).
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Affiliation(s)
- Chantal A Ten Kate
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Cornelius E J Sloots
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Erica L T van den Akker
- Department of Pediatric Endocrinology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Rene M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
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Ten Kate CA, Vlot J, IJsselstijn H, Allegaert K, Spaander MCW, Poley MJ, van Rosmalen J, van den Akker ELT, Wijnen RMH. Intralesional steroid injections to prevent refractory strictures in patients with oesophageal atresia: study protocol for an international, multicentre randomised controlled trial (STEPS-EA trial). BMJ Open 2019; 9:e033030. [PMID: 31848172 PMCID: PMC6937109 DOI: 10.1136/bmjopen-2019-033030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Anastomotic stricture formation is the most common postoperative complication after oesophageal atresia (OA) repair. The standard of care is endoscopic dilatation. A possible adjuvant treatment is intralesional steroid injection, which is thought to inhibit scar tissue formation and thereby to prevent stricture recurrence. We hypothesise that this intervention could prevent refractory strictures and reduce the total number of dilatations needed in these children. METHODS AND ANALYSIS This is an international multicentre randomised controlled trial. Children with OA type C (n=110) will be randomised into intralesional steroid injection followed by balloon dilatation or dilatation only. Randomisation and intervention will take place when a third dilatation is performed. The indication for dilatation will be confirmed with an oesophagram. One radiologist-blinded for randomisation-will review all oesophagrams. The primary outcome parameter is the total number of dilatations needed with <28 days' interval, which will be analysed with a linear-by-linear χ2 association test. Secondary outcome parameters include the level of dysphagia, the luminal oesophageal diameter and stricture length (measured on the oesophagrams), the influence of comedication on stricture formation, systemic effects of intralesional steroids (cortisol levels, length and weight) and the cost-effectiveness. Patients will undergo a second oesophagram; length and weight will be measured repeatedly; a scalp hair sample will be collected; and three questionnaires will be administered. The follow-up period will be 6 months, with evaluation at 2-3 weeks, 3 and 6 months after the intervention. ETHICS AND DISSEMINATION Patients will be included after written parental informed consent. The risks and burden associated with this trial are minimal. The institutional review board of the Erasmus Medical Centre approved this protocol (MEC-2018-1586/NL65364.078.18). The results of the trial will be published in a peer-reviewed scientific journal and will be presented at international conferences. TRIAL REGISTRATION NUMBERS 2018-002863-24 and NTR7726/NL7484.
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Affiliation(s)
- Chantal A Ten Kate
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - John Vlot
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Department of Paediatric Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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Qiu Y, Shi R. Roles of Steroids in Preventing Esophageal Stricture after Endoscopic Resection. Can J Gastroenterol Hepatol 2019; 2019:5380815. [PMID: 31058109 PMCID: PMC6463667 DOI: 10.1155/2019/5380815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/20/2019] [Accepted: 03/07/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSES Endoscopic resection has been worldwide recognized as a treatment strategy for early esophageal lesions. The occurrence of esophageal stricture after endoscopic resection will reduce the quality of life of patients. This study will evaluate the efficacy and safety of steroids in the prevention of esophageal stricture after endoscopic resection and the influence of different steroid administration methods. METHODS In the relevant literature database, literature from 2008 to 2018 is retrieved by using preset keywords, the search results are carefully screened, and the conclusion of the literature is synthesized to form arguments and draw conclusions. RESULTS 73 articles met our requirements. Oral steroid administration, not prophylactic endoscopic balloon dilation alone, was effective in preventing esophagostenosis after esophagoscopic treatment and reducing the number of repeated endoscopic balloon dilations even after extensive endoscopic resection. Local steroid injection is useful and economy for preventing esophageal stricture, even though it may raise the risk of perforation during dilations. A wider range of circumferential mucosal defects is an independent predictor for stricture formation for patents given preventive steroid injections after endoscopic submucosal dissection. For complete circular mucosal defect, the further researches are essential to investigate the role of local steroid injection. The effect of other methods such as steroid gel, intravenous infusion of steroid, and novel steroid filling methods require more confirmation. CONCLUSIONS Therefore, steroids play an irreplaceable role in preventing esophageal stricture after endoscopic resection. Oral and local injections of steroids are the two most acceptable methods and more prospective studies are needed to compare the effectiveness and safety of these two methods.
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Affiliation(s)
- Yu Qiu
- Medical School of Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, China
- Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, China
| | - Ruihua Shi
- Medical School of Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, China
- Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, China
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Wang W, Shen Z, Du B, Pang Y. PRISMA - Practical meta-analysis of applying local triamcinolone acetonide injection for stenosis after esophageal cancer surgery. Cancer Manag Res 2018; 10:6327-6338. [PMID: 30568495 PMCID: PMC6267765 DOI: 10.2147/cmar.s173769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To explore the practical method of endoscopic triamcinolone acetonide (TA) injection immediately after endoscopic surgery and combined with endoscopic dilation (ED) in the management of stenosis after esophageal cancer surgery based on their efficacy and safety. Methods A comprehensive search was performed in electronic databases including MEDLINE, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure for possible controlled studies. Meta-analyses of the included studies were completed using Reviewer Manager software and were reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results Eight randomized studies and five controlled studies containing 575 patients were obtained. In five studies (n=282), TA injected after surgery reduced the risk of stenosis (risk difference [RD] =-0.51, 95% CI [-0.64, -0.39], P<0.01) and the required ED sessions (RD =-3.66, 95% CI [-5.87, -1.46], P<0.01). In eight studies (n=293), TA injection combined with ED reduced the risk of recurrence of stenosis (RD =-0.28, 95% CI [-0.47, -0.08], P<0.01) and the required ED sessions (RD =-0.71, 95% CI [-1.39, -0.04], P<0.05). TA injection therapy did not increase the risk of complications in seven studies (n=380; RD =-0.01, 95% CI [-0.04, 0.02], P=0.53) compared with control. Conclusion TA injection therapy after esophageal cancer surgery and combined with ED are both effective and safe in the management of stenosis, as they reduce the risk of stenosis and sequentially the required ED sessions without increasing complications.
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Affiliation(s)
- Wu Wang
- Laboratory of Tropical Biomedicine and Biotechnology, School of Tropical Medicine and Laboratory Medicine, Hainan Medical University, Haikou, Hainan 570100, China
| | - Zhen Shen
- Division of Liver Disease, Huangshi City Hospital of Traditional Chinese Medicine (Infectious Disease Hospital), Edong Healthcare Group, Huangshi, Hubei 435000, China
| | - Baoxin Du
- Department of Urology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 402760, China
| | - Yanyang Pang
- Department of Traditional Chinese Medicine, Hainan Medical University, Haikou, Hainan 570100, China,
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Endoscopic Balloon Dilation Followed By Intralesional Steroid Injection for Anastomotic Strictures After Esophagectomy: A Randomized Controlled Trial. Am J Gastroenterol 2018; 113:1468-1474. [PMID: 30181533 DOI: 10.1038/s41395-018-0253-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic balloon dilation (EBD) is a standard treatment for anastomotic strictures after esophagectomy, and requires multiple dilations. We conducted a randomized controlled trial to assess the efficacy of adding a steroid injection to EBD to reduce restricture. METHODS Patients were randomized to receive EBD combined with either triamcinolone or placebo injection. The primary endpoint was the number of dilations required to resolve the stricture. The secondary endpoints were restricture-free survival and adverse events. Patients with a dysphagia symptom score of ≥2 after esophagectomy with an endoscopy-confirmed anastomotic stricture were included. A total of 50 mg of triamcinolone acetonide (50 mg/5 mL) or an identical volume of normal saline solution as a placebo was injected per site using a 25-gauge needle immediately after EBD. Both the patient and treating physician were blinded to the treatment given. RESULTS During the 4-year study period, 65 patients were randomized to either the steroid group (n = 33) or placebo group (n = 32). The median number of EBDs required to resolve strictures was 2.0 (interquartile range, 1.0-2.5) in the steroid group and 4.0 (interquartile range, 2.0-6.8) in the placebo group (p < 0.001). After 6 months of follow-up, 39% of patients who had received steroid injections remained recurrence free compared with 16% of those who had received saline injections (p = 0.002). No adverse events occurred during follow-up. CONCLUSIONS Steroid injection shows promising results for the prevention of stricture recurrence in patients who underwent EBD for anastomotic strictures.
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Efficacy and Safety of Endoscopic Intralesional Triamcinolone Injection for Benign Esophageal Strictures. Gastroenterol Res Pract 2018; 2018:7619298. [PMID: 30158968 PMCID: PMC6109539 DOI: 10.1155/2018/7619298] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/05/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022] Open
Abstract
Objectives To evaluate the efficacy and safety of endoscopic intralesional triamcinolone injection (ITI) for benign esophageal strictures combined with endoscopic dilation (ED). Methods Online databases including MEDLINE, EMBASE, the Cochrane Library, and Web of Science were comprehensively searched for prospective randomized control trials (RCTs) between 1966 and March 2018. A meta-analysis was conducted according to the methods recommended by the Cochrane Collaboration. Results Six RCTs consisting of 176 patients were selected. Meta-analysis results showed that additional ITI had a significant advantage in terms of stricture rate and required ED sessions. Surgery-related and non-surgery-related strictures showed similar results. Additional ITI was not associated with significantly increased risk of complications. Conclusions Our meta-analysis showed that additional ITI therapy was supposed to be effective and safe for benign esophageal strictures as it reduced the stricture rate and required ED sessions. However, more RCTs are necessary to support these findings.
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Szapáry L, Tinusz B, Farkas N, Márta K, Szakó L, Meczker Á, Hágendorn R, Bajor J, Vincze Á, Gyöngyi Z, Mikó A, Csupor D, Hegyi P, Erőss B. Intralesional steroid is beneficial in benign refractory esophageal strictures: A meta-analysis. World J Gastroenterol 2018; 24:2311-2319. [PMID: 29881240 PMCID: PMC5989245 DOI: 10.3748/wjg.v24.i21.2311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the effect of intralesional steroid injections in addition to endoscopic dilation of benign refractory esophageal strictures. METHODS A comprehensive search was performed in three databases from inception to 10 April 2017 to identify trials, comparing the efficacy of endoscopic dilation to dilation combined with intralesional steroid injections. Following the data extraction, meta-analytical calculations were performed on measures of outcome by the random-effects method of DerSimonian and Laird. Heterogeneity of the studies was tested by Cochrane's Q and I2 statistics. Risk of quality and bias was assessed by the Newcastle Ottawa Scale and JADAD assessment tools. RESULTS Eleven articles were identified suitable for analyses, involving 343 patients, 235 cases and 229 controls in total. Four studies used crossover design with 121 subjects enrolled. The periodic dilation index (PDI) was comparable in 4 studies, where the pooled result showed a significant improvement of PDI in the steroid group (MD: -1.12 dilation/month, 95%CI: -1.99 to -0.25 P = 0.012; I2 = 74.4%). The total number of repeat dilations (TNRD) was comparable in 5 studies and showed a non-significant decrease (MD: -1.17, 95%CI: -0.24-0.05, P = 0.057; I2 = 0), while the dysphagia score (DS) was comparable in 5 studies and did not improve (SMD: 0.35, 95%CI: -0.38, 1.08, P = 0.351; I2 = 83.98%) after intralesional steroid injection. CONCLUSION Intralesional steroid injection increases the time between endoscopic dilations of benign refractory esophageal strictures. However, its potential role needs further research.
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Affiliation(s)
- László Szapáry
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Benedek Tinusz
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Ágnes Meczker
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Roland Hágendorn
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Judit Bajor
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Dezső Csupor
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs 7624, Hungary
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The Efficacy of Intralesional Steroid Injection in the Treatment of Corrosive Esophageal Strictures in Children. Surg Laparosc Endosc Percutan Tech 2017; 26:e122-e125. [PMID: 27846162 DOI: 10.1097/sle.0000000000000351] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF THE STUDY Esophageal dilatation can be insufficient in the treatment of severe corrosive esophageal strictures. In this study, we aimed to present the efficacy of intralesional steroid injection as an adjunct to dilatation therapy. MATERIALS AND METHODS Retrospective analysis of children who underwent intralesional steroid injection between 2004 and 2014 was performed. Patients' age, type of corrosive substance, length of stricture, number of injection and dilatation sessions and complications were reviewed. The success was evaluated by the comparison of number, frequency, and requirement of dilatation therapy before and after injection. RESULTS Intralesional steroid injection was performed to 32 children with a mean age of 3.6±2.5 years. The types of corrosive agents were alkali (24) or acid (8). Mean number of injection sessions was 2.5±1.1(1 to 6). Mean number of dilatation sessions was decreased from 10±8.8 to 5.4±4.6 after injection (P=0.003). Mean frequency of dilatations was extended from 3.6±0.9 weeks to 8.7±3.9 weeks (P=0.000). Dilatation treatment was successfully terminated in 25 of 27 children with short-segment strictures after injection (92%). Whereas all of the children with long-segment strictures could not resolved and finally required esophageal replacement (5 patients). One patient had transient cushingoid phenotype as a complication. There was not seen any major complication-like perforation. The mean follow-up period was 6±3 years. CONCLUSIONS Intralesional steroid injection is an effective adjunct to dilatation in most of the children with short-segment strictures. It should be performed as a safe and efficient treatment option in patients with short-segment corrosive esophageal strictures resistant to dilatation therapy.
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Tambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V, Contini AC, Romeo E, Rea F, Faraci S, Federici di Abriola G, Dall'Oglio L. Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures. Front Pediatr 2017; 5:120. [PMID: 28611969 PMCID: PMC5447026 DOI: 10.3389/fped.2017.00120] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/04/2017] [Indexed: 01/10/2023] Open
Abstract
Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,University of L'Aquila, L'Aquila, Italy
| | - Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Filippo Torroni
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Contini
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Erminia Romeo
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Tan Y, Zhang J, Zhou J, Duan T, Liu D. Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children. J Pediatr Gastroenterol Nutr 2015; 61:319-322. [PMID: 25844710 DOI: 10.1097/mpg.0000000000000801] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients. METHODS We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up. RESULTS All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3-4 to 0-1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2-5 mm) to 10.6 mm (range 8-12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up. CONCLUSIONS EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.
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Affiliation(s)
- Yuyong Tan
- Department of Gastroenterology, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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16
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In-Office Esophageal Procedures. CURRENT OTORHINOLARYNGOLOGY REPORTS 2015. [DOI: 10.1007/s40136-015-0092-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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18
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Funakawa K, Uto H, Sasaki F, Nasu Y, Mawatari S, Arima S, Nakazawa J, Taguchi H, Hashimoto S, Kanmura S, Setoyama H, Numata M, Tsubouchi H, Ido A. Effect of endoscopic submucosal dissection for superficial esophageal neoplasms and risk factors for postoperative stricture. Medicine (Baltimore) 2015; 94:e373. [PMID: 25569662 PMCID: PMC4602840 DOI: 10.1097/md.0000000000000373] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/17/2014] [Accepted: 11/21/2014] [Indexed: 12/16/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) enables wider tumor resection compared with endoscopic mucosal resection and en bloc resection of superficial esophageal neoplasms. However, ESD may cause difficult-to-treat stricture of the esophagus, and therefore, prediction of and measures against postoperative esophageal stricture are critical. The aim of this study was to evaluate the effect of ESD on superficial esophageal neoplasms and identify risk factors associated with esophageal stricture after ESD.This study included 165 lesions in 120 patients with superficial esophageal neoplasms, including cancer and neoplasia, who underwent ESD from 2009 to 2013.The complete resection rate of superficial esophageal neoplasms by ESD was 90.9%. After ESD, 22 subjects (18.3%) had symptomatic esophageal stricture, 12 (10.0%) had aspiration pneumonia of grade 2, and 7 (5.8%) had mediastinal emphysema of grade 2. Comparison of the 22 subjects with stricture with the 98 subjects without stricture showed significant differences in the rate of resection of >75% of the esophageal circumference, rate of whole circumference resection, and the required time for resection. The tumor size and the size of the resected tissue sample also differed between the 2 groups. The groups did not differ in age, sex, alcohol intake, and smoking; location, macroscopic, and histological tumor findings; chest pain; or use of anticoagulants for comorbidities. In multivariate analysis, tumor size and whole circumference resection were independent risk factors for stricture. Furthermore, in 45 subjects with resection of >75% of the esophageal circumference, whole resection of the esophagus was the only independent risk factor for stricture.This study suggests that ESD has a strong therapeutic effect on superficial esophageal neoplasms; however, a greater extent of resection of the esophagus increases the risk of postoperative esophageal stricture. Preventive measures against development of postoperative stricture require further study.
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Affiliation(s)
- Keita Funakawa
- From the Digestive and Lifestyle Diseases (KF, HU, FS, YN, SM, SA, JN, H. Taguchi, SH, SK, HS, MN, AI), Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences; Department of Internal Medicine (KF, H. Tsubouchi), Kagoshima City Hospital; and Department of HGF Tissue Repair and Regenerative Medicine (H. Tsubouchi, AI), Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Agarwalla A, Small AJ, Mendelson AH, Scott FI, Kochman ML. Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures. Surg Endosc 2014; 29:1903-12. [PMID: 25277484 DOI: 10.1007/s00464-014-3883-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 09/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation. METHODS Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007-October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed. RESULTS 63 patients underwent 303 dilations. All presented with a stricture >30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (±2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR 22.88; 95% CI 3.19-164.07), severe esophageal stenosis (lumen <9 mm) (OR 10.51; 95% CI 1.94-56.88), and proximal location with prior malignancy extrinsic to the lumen (OR 6.96; 95% CI 1.33-36.29) were independent predictors of refractory strictures in multivariate analysis. CONCLUSIONS (1) Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. (2) Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. (3) Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. (4) Clinical and procedural predictors may identify patients at high risk of refractory strictures. (5) The optimal strategy in highly selected refractory patients is not clear.
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Affiliation(s)
- Anant Agarwalla
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sato H, Inoue H, Kobayashi Y, Maselli R, Santi EGR, Hayee B, Igarashi K, Yoshida A, Ikeda H, Onimaru M, Aoyagi Y, Kudo SE. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78:250-7. [PMID: 23453294 DOI: 10.1016/j.gie.2013.01.008] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 01/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD). OBJECTIVE To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus). INTERVENTION After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks. MAIN OUTCOME MEASUREMENTS Total number of EBD sessions and total EBD period (months). RESULTS Steroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group. LIMITATIONS Nonrandomized study; retrospective analysis. CONCLUSION After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD.
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Affiliation(s)
- Hiroki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
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Efficacy of intralesional corticosteroid injection in endoscopic treatment of esophageal strictures. Surg Laparosc Endosc Percutan Tech 2013; 22:518-22. [PMID: 23238379 DOI: 10.1097/sle.0b013e3182747b31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The present study was conducted to determine the effectiveness of intralesional triamcinolone to improve the results of endoscopic dilation in esophageal strictures. METHODS We treated 9 patients with complex strictures of different etiologies (2 postsurgery, 3 gastroesophageal reflux disease, and 4 caustic) with intralesional injections of triamcinolone followed by endoscopic dilations. Outcomes of triamcinolone-treated patients were compared with those of historical control. We injected triamcinolone before dilating the strictures. All the patients were followed up for 1 year. The interval between dilations, frequency of dilation, and refractory rates were calculated. RESULTS There was no difference between the control group and the patients with steroids regarding baseline characteristics (age and sex distribution of patients and stricture etiologies, length, and location). The patients in the triamcinolone group had a bigger improvement of their dysphagia and had a lower refractority rate than the patients in control group, these differences being statistically significant. CONCLUSIONS Intralesional triamcinolone presented a higher improvement of dysphagia and a lower refractority rate in patients with complex strictures with statistically significant differences.
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Lévesque D, Baird R, Laberge JM. Refractory strictures post-esophageal atresia repair: what are the alternatives? Dis Esophagus 2013; 26:382-7. [PMID: 23679028 DOI: 10.1111/dote.12047] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58-96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1-0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non-surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.
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Affiliation(s)
- D Lévesque
- Gastroenterology and Pediatric General Surgery Divisions, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada H3H1P3.
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Nonaka K, Miyazawa M, Ban S, Aikawa M, Akimoto N, Koyama I, Kita H. Different healing process of esophageal large mucosal defects by endoscopic mucosal dissection between with and without steroid injection in an animal model. BMC Gastroenterol 2013; 13:72. [PMID: 23617935 PMCID: PMC3652745 DOI: 10.1186/1471-230x-13-72] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 04/24/2013] [Indexed: 02/07/2023] Open
Abstract
Background Stricture formation is one of the major complications after endoscopic removal of large superficial squamous cell neoplasms of the esophagus, and local steroid injections have been adopted to prevent it. However, fundamental pathological alterations related to them have not been well analyzed so far. The aim of this study was to analyze the time course of the healing process of esophageal large mucosal defects resulting in stricture formation and its modification by local steroid injection, using an animal model. Methods Esophageal circumferential mucosal defects were created by endoscopic mucosal dissection (ESD) for four pigs. One pig was sacrificed five minutes after the ESD, and other two pigs were followed-up on endoscopy and sacrificed at the time of one week and three weeks after the ESD, respectively. The remaining one pig was followed-up on endoscopy with five times of local steroid injection and sacrificed at the time of eight weeks after the ESD. The esophageal tissues of all pigs were subjected to pathological analyses. Results For the pigs without steroid injection, the esophageal stricture was completed around three weeks after the ESD on both endoscopy and esophagography. Histopathological examination of the esophageal tissues revealed that spindle-shaped α-smooth muscle actin (SMA)-positive myofibroblasts arranged in a parallel fashion and extending horizontally were identified at the ulcer bed one week after the ESD, and increased contributing to formation of the stenotic luminal ridge covered with the regenerated epithelium three weeks after the ESD. The proper muscle layer of the stricture site was thinned with some myocytes which seemingly showed transition to the myofibroblast layer. By contrast, for the pig with steroid injection, esophageal stricture formation was not evident with limited appearance of the spindle-shaped myofibroblasts, instead, appearance of stellate or polygocal SMA-positive stromal cells arranged haphazardly in the persistent granulation tissue of the ulcer site. Conclusions Proliferation of spindle-shaped myofibroblasts arranged in a parallel fashion is likely to play an important role in stricture formation after circumferential mucosal defects by esophageal ESD, which may be related to the thinning of the proper muscle layer in the healing course of the defects. Local steroid injection seems to be effective to prevent the stricture through the modification of this process.
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Affiliation(s)
- Kouichi Nonaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, 350-1298, Japan
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Matsui N, Akahoshi K, Nakamura K, Ihara E, Kita H. Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: A technical review. World J Gastrointest Endosc 2012; 4:123-36. [PMID: 22523613 PMCID: PMC3329612 DOI: 10.4253/wjge.v4.i4.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/13/2011] [Accepted: 03/30/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.
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Affiliation(s)
- Noriaki Matsui
- Noriaki Matsui, Department of Gastroenterology and Hepatology, National Hospital Organization Fukuoka Higashi Medical Center, Koga 811-3195, Japan
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Abstract
Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.
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Honda M, Nakamura T, Hori Y, Shionoya Y, Yamamoto K, Nishizawa Y, Kojima F, Shigeno K. Feasibility study of corticosteroid treatment for esophageal ulcer after EMR in a canine model. J Gastroenterol 2011; 46:866-72. [PMID: 21597933 DOI: 10.1007/s00535-011-0400-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 01/30/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intralesional or systemic steroid administration is a promising strategy for the prevention of esophageal stricture after endoscopic therapy. The aim of this study was to evaluate the influence of steroid therapy on the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR). METHODS Nine beagle dogs were divided into three equal groups: group A, intralesional injection (n = 3), group B, peroral administration (n = 3), and group C, untreated control (n = 3). In group A, triamcinolone acetonide 1 ml (10 mg) was injected directly into the exposed submucosal layer immediately after EMR, and again on postoperative day (POD) 7. In group B, dogs were administered prednisolone 0.5 mg/kg/day orally for 14 days after EMR. In group C, 1 ml normal saline was injected by the same method as that used for group A. On POD 28, histological examination was performed to evaluate epithelialization, inflammation, angiogenesis, and atrophy of the muscularis propria. RESULTS In groups A, B, and C, the mean ulcer area was 50.1, 22.7, and 7.4 mm(2), respectively. The difference between groups A and C was significant (p < 0.01). Inflammatory cells were significantly more evident in the lesions of group A than in those of group C (p < 0.05). In all groups, atrophy of the muscularis propria was evident. However, transmural destruction and fibrosis were observed only in group A. CONCLUSION It was speculated that the esophageal ulcer causes the fibrosis of the submucosa and atrophy of the muscularis propria during process of healing. Intralesional steroid injection deepened the esophageal ulcers and delayed epithelialization, whereas systemic administration did not clearly improve the lesion healing process.
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Affiliation(s)
- Michitaka Honda
- Department of Bioartificial Organs, Institute for Frontier Medical Science, Kyoto University, 53 Kawahara cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Heran MKS, Pham TH, Butterworth S, Robinson A. Use of a microporous polytetrafluoroethylene catheter balloon to treat refractory esophageal stricture: a novel technique for delivery of mitomycin C. J Pediatr Surg 2011; 46:776-779. [PMID: 21496555 DOI: 10.1016/j.jpedsurg.2010.11.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 11/09/2010] [Accepted: 11/18/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Endoluminal application of mitomycin C shows promise as a nonsurgical approach to treating recalcitrant stricture but requires precise delivery to prevent mitomycin-mediated injury to adjacent normal mucosa. We describe a novel technique that uses a microporous polytetrafluoroethylene catheter balloon to endoluminally deliver mitomycin C to the target tissue while minimizing nontarget drug application. MATERIALS AND METHODS A newborn infant with proximal tracheoesophageal fistula and distal atresia underwent an uncomplicated repair. However, he developed recurrent esophageal stricture resistant to multiple attempts at pneumatic dilations. An image-guided endoluminal radiologic approach that uses microporous polytetrafluoroethylene catheter balloon was developed to precisely deliver mitomycin C to the mucosal lining of the stricture post-dilation. RESULTS After uncomplicated pneumatic dilation under fluoroscopic guidance, we used a microporous balloon catheter to endoluminally deliver mitomycin C topically to the mucosa at the level of stricture. Three weeks post procedure, repeat esophagram showed resolution of the stricture with unobstructed flow of contrast material to the stomach. The patient had no observable side effects from mitomycin C application. CONCLUSION Image-guided therapies based on balloon dilation and drug-eluting microporous balloon techniques offer a safe, precise, and comprehensive approach to the treatment of recalcitrant esophageal strictures.
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Affiliation(s)
- Manraj K S Heran
- Department of Radiology, BC Children's Hospital, Vancouver, Canada V6H 3V4.
| | - Tuan H Pham
- Division of Pediatric Surgery, Cardon Children's Medical Center, Mesa, AZ, USA
| | - Sonia Butterworth
- Division of Pediatric Surgery, BC Children's Hospital, Vancouver, BC, Canada V6H 3V4
| | - Ashley Robinson
- Department of Radiology, BC Children's Hospital, Vancouver, Canada V6H 3V4
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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: 98] [Impact Index Per Article: 6.1] [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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Nonsurgical management of severe esophageal and gastric injury following alkali ingestion. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 21:757-60. [PMID: 18026581 DOI: 10.1155/2007/218103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The ingestion of caustic substances may result in significant gastrointestinal injury. Endoscopy can play a major role in the initial evaluation and subsequent therapy of such injuries. The case of a 50-year-old man who ingested an alkaline floor stripper is described, including the endoscopic management of esophageal and pyloric strictures, with good functional results. The role of endoscopy, steroids and acid suppression in the management of such patients is also explored.
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Chang AC, Orringer MB. Management of the cervical esophagogastric anastomotic stricture. Semin Thorac Cardiovasc Surg 2007; 19:66-71. [PMID: 17403460 DOI: 10.1053/j.semtcvs.2006.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2006] [Indexed: 12/28/2022]
Abstract
Esophagogastric anastomotic stricture following esophagectomy with a gastric esophageal substitute can be a vexing problem for the patient and treating physician. We describe the clinical practice at a single center with extensive experience in esophageal surgery for management of this complication.
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Affiliation(s)
- Andrew C Chang
- Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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31
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Yeh RW, Triadafilopoulos G. Injection therapies for nonbleeding disorders of the GI tract. Gastrointest Endosc 2006; 64:399-411; quiz 389-92. [PMID: 16923490 DOI: 10.1016/j.gie.2006.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 04/17/2006] [Indexed: 12/20/2022]
Affiliation(s)
- Ronald W Yeh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Seymour CW, Krimsky WS, Sager J, Kruklitis RJ, Lund ME, Musani AI, Sterman DH. Transbronchial Needle Injection: A Systematic Review of a New Diagnostic and Therapeutic Paradigm. Respiration 2006; 73:78-89. [PMID: 16498271 DOI: 10.1159/000090994] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Accepted: 07/20/2005] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Transbronchial needle catheters are commonly used during flexible and rigid bronchoscopy for needle aspiration. The use of these catheters can be expanded by employing the technique of transbronchial needle injection. METHODS AND RESULTS By injecting lesions in the airways, peribronchial structures, mediastinum, or lung parenchyma, transbronchial needle injection has been applied to the treatment of lung cancer, inflammatory disorders of the airways, recurrent respiratory papillomatosis, as well as bronchopleural fistulas. Diagnostic applications have included the localization of peripheral lung nodules as well as sentinel lymph nodes. CONCLUSIONS Our review defines this bronchoscopic technique and summarizes its various reported applications.
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Affiliation(s)
- Christopher W Seymour
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA
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33
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Abstract
Patients with progressive or solid food dysphagia should be evaluated for the presence of an esophageal stricture. Barium esophagram and endoscopy can define strictures as benign or malignant. The majority of benign strictures are acid-related. Benign strictures are best managed by esophageal dilation with acid-suppressing medications if a peptic stricture is suspected. If dysphagia recurs, repeat dilation should be performed. There are a variety of interventions for refractory strictures which include injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents and surgery.
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Ramage JI, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murray JA, Norton ID, Diehl N, Romero Y. A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 2005; 100:2419-25. [PMID: 16279894 DOI: 10.1111/j.1572-0241.2005.00331.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The aim of the study was to examine whether endoscopic intralesional corticosteroid injection into recalcitrant peptic esophageal strictures reduces the need for repeat stricture dilation. METHODS Patients with a peptic esophageal stricture and recurrent dysphagia having had at least one dilation in the preceding 18 months were enrolled in a prospective randomized, double-blind study comparing steroid and sham injection. After endoscopic confirmation of recurrent stricture, patients were randomized to receive either 0.5 cc/quadrant triamcinolone (40 mg/cc) or sham injection into the stricture followed by balloon dilation of the stricture. Patients were stratified by the number of dilations required in the preceding 18 months, severity of dysphagia, the presence of esophagitis, stricture severity, and prior therapy with a proton-pump inhibitor. Patients and their physicians were blinded to the type of intervention received. Baseline dysphagia questionnaires were completed. Post-procedurally all patients were placed on a standardized proton-pump inhibitor regimen and standardized telephone follow-up questionnaires were completed at 1 wk and at 1, 3, 6, 9, and 12 months. The original sample-size calculation of 60 patients could not be met in a timely fashion because of a low incidence of recalcitrant peptic stricture patients. RESULTS A total of 30 patients were enrolled, 15 in the steroid group (10 men, mean age 66 yr) and 15 in the sham group (11 M, mean age 67 yr). Patients were followed for 1 yr, unless they underwent an antireflux operation or died. Two patients, one per group, died of non-esophageal causes at 1 and 12 months. Four patients had fundoplication, two in each group, unrelated to stricture or dysphagia. Two patients in the steroid group (13%) and nine in the sham group (60%) required repeat dilation (p= 0.011). CONCLUSIONS In patients with recalcitrant peptic esophageal stricture, steroid injection into the stricture combined with acid suppression significantly diminishes both the need for repeat dilation and the average time to repeat dilation compared to sham injection and acid suppression alone.
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Affiliation(s)
- Jack I Ramage
- Division of Gastroenterology & Hepatology, Mayo Clinic Foundation, Rochester, Minnesota, USA
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35
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Beilstein MC, Kochman ML. Endoscopic incision of a refractory esophageal stricture: novel management with an endoscopic scissors. Gastrointest Endosc 2005; 61:623-5. [PMID: 15812426 DOI: 10.1016/s0016-5107(04)02787-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michelle C Beilstein
- Gastroenterology Division, Department of Medicine University of Pennsylvania Health System, Philadelphia, PA 19104, 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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37
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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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38
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Liangpunsakul S, Rex DK. Management of benign colonic strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2003. [DOI: 10.1053/j.tgie.2003.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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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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40
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Keate RF, Williams JW, Connolly SM. Lichen planus esophagitis: report of three patients treated with oral tacrolimus or intraesophageal corticosteroid injections or both. Dis Esophagus 2003; 16:47-53. [PMID: 12581256 DOI: 10.1046/j.1442-2050.2003.00289.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinically significant involvement of the esophagus is uncommon in patients who have lichen planus, a common disorder of squamous epithelium. In three patients who had oral, cutaneous, and esophageal lichen planus, endoscopic intralesional esophageal injection of corticosteroids (in all three patients) and oral tacrolimus (FH506) (in two patients) resulted in improvement in dysphagia, a less frequent need for dilation, and improvement in esophageal inflammation.
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Affiliation(s)
- R F Keate
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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41
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Abstract
Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.
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Affiliation(s)
- Craig W Lillehei
- Department of Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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42
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Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002; 56:829-834. [PMID: 12447293 DOI: 10.1016/s0016-5107(02)70355-6] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The cornerstone treatment for benign esophageal strictures is endoscopic dilation. There are reports suggesting that intralesional corticosteroid injection decreases the frequency of endoscopic dilation. METHODS Seventy-one patients (mean age 42.39 [17.52] years; range, 13-78 years) with benign esophageal strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9) were recruited for this study. All were being managed with a program of intermittent endoscopic dilation by using over-the-wire polyvinyl dilators. All patients were treated by intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) by using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL. At each session, 4 injections (4 quadrants) were made at the proximal margin of the stricture with another 4 injections into the strictured segment itself whenever possible. The intervals between dilations and frequency of dilations were calculated before and after triamcinolone injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated. RESULTS The overall mean (SD) duration of treatment before intralesional injection was 10.9 (19.8) months (range, 1-120 months) and the mean number (SD) of esophageal dilations required was 9.67 (13.06) (range, 1-70). The mean number of sessions of intralesional injection was 1.4 (0.62). After initiation of intralesional injections mean follow-up was 8.1 (5.6) months (range 3-30 months) and the mean number of esophageal dilations was 3.8 (3.0) (range 0-16). The periodic dilation index decreased significantly from 1.24 (0.05) (range 0.13-3.16) before injection to 0.5 (0.33) (range, 0-2) after injection (p < 0.001). For each category of stricture, the periodic dilation index decreased significantly: corrosive, 1.24 (0.5) to 0.53 (0.34) (p < 0.001); peptic, 0.92 (0.44) to 0.42 (0.2) (p < 0.001); anastomotic, 1.24 (0.49) to 0.51 (0.4) (p < 0.001); and radiation-induced, 1.32 (0.6) to 0.6 (0.3) (p < 0.02). CONCLUSION Intralesional injections of triamcinolone augment the effects of dilation in patients with benign esophageal strictures.
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Affiliation(s)
- Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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43
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Abstract
Esophageal strictures from a variety of benign and malignant causes require dilation therapy when patients develop symptoms of dysphagia. Dilation can be accomplished using a variety of dilating devices and adjunctive techniques. The approach to management of esophageal strictures is reviewed with a focus on dilation technique and special considerations for various stricture types.
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Affiliation(s)
- Ronald J Lew
- Medicine Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
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44
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Leib MS, Dinnel H, Ward DL, Reimer ME, Towell TL, Monroe WE. Endoscopic Balloon Dilation of Benign Esophageal Strictures in Dogs and Cats. J Vet Intern Med 2001. [DOI: 10.1111/j.1939-1676.2001.tb01589.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Affiliation(s)
- M Kirsch
- Cleveland Clinic Foundation, Ohio 44195-5001
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46
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Abstract
PURPOSE This study was undertaken to examine the effect of local injection of potent steroids on recurrence of Crohn's disease strictures. METHODS Ten patients with colonic strictures attributable to Crohn's disease were treated by dilation and injection of triamcinolone. Five of them had postoperative strictures. RESULTS Patients were followed for 1.5 to 3 years. Two patients required additional dilation and injection of steroids after one year. Eight patients remained well. CONCLUSION Local injection of steroids improves outcome in strictures caused by Crohn's disease.
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Affiliation(s)
- A Lavy
- Gastroenterology Unit, Rambam Medical Center, Haifa, Israel
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47
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Zein NN, Greseth JM, Perrault J. Endoscopic intralesional steroid injections in the management of refractory esophageal strictures. Gastrointest Endosc 1995; 41:596-8. [PMID: 7672556 DOI: 10.1016/s0016-5107(95)70198-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- N N Zein
- Department of Pediatrics, Section of Pediatric Gastroenterology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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48
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Lee M, Kubik CM, Polhamus CD, Brady CE, Kadakia SC. Preliminary experience with endoscopic intralesional steroid injection therapy for refractory upper gastrointestinal strictures. Gastrointest Endosc 1995; 41:598-601. [PMID: 7672557 DOI: 10.1016/s0016-5107(95)70199-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- M Lee
- Division of Gastroenterology, University of Texas Health Science Center, San Antonio 78284-7878, USA
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49
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Ranne RD, Lindley S, Holder TM, Ashcraft KW, Sharp RJ, Amoury RA. Relief of subglottic stenosis by anterior cricoid resection: an operation for the difficult case. J Pediatr Surg 1991; 26:255-8; discussion 258-9. [PMID: 2030469 DOI: 10.1016/0022-3468(91)90498-i] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Anterior cricoid resection is an effective procedure to relieve subglottic stenosis. This is well documented in adults, although reports of the procedure in growing airways are limited. Over an 11-year period, seven pediatric patients underwent anterior cricoid resection for recalcitrant subglottic stenosis. In four patients, the stricture was secondary to prolonged intubation, one developed subglottic stenosis following a high placement of tracheostomy for epiglottitis and another had congenital subglottic stenosis. One child had subglottic stenosis combined with laryngotracheoesophageal cleft and more distally located tracheoesophageal fistula. All patients had failed to respond to previous treatment: dilatations (3 to 20), steroid injection (3 patients), and Evan's tracheoplasty (2 patients). All patients had an excellent result from anterior cricoid resection. The median age of children undergoing anterior cricoid resection was 3 years. There was no mortality. Tracheostomy decannulation was accomplished within 12 weeks following operation in all patients. It was necessary to remove a tracheal granuloma in one patient. Anterior cricoid wedge resection leaving the posterior portion of the cricoid in place is done to avoid recurrent nerve injury. It is a relatively simple and effective procedure. There has been minimal morbidity and no mortality. Follow-up from 1 to 11 years shows no recurrence of stenosis. There has been normal laryngeal and airway growth.
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Affiliation(s)
- R D Ranne
- Children's Mercy Hospital, Kansas City, MO 64108
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Gandhi RP, Cooper A, Barlow BA. Successful management of esophageal strictures without resection or replacement. J Pediatr Surg 1989; 24:745-9; discussion 749-50. [PMID: 2769540 DOI: 10.1016/s0022-3468(89)80529-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Esophageal resection or replacement has become the standard therapy for severe esophageal strictures chiefly because less aggressive methods generally have failed. We hereby report our experience with 12 consecutive infants and children who have been managed successfully by means of Stamm gastrostomy and string-guided esophageal dilatation, coupled with endoscopically guided four-quadrant intralesional steroid injection, protected by Nissen fundoplication when gastroesophageal reflux has been demonstrated. In six patients, the stricture(s) were caused by ingestion of lye. In five, they were associated with repair of esophageal atresia. In one, the etiology was never determined. The strictures averaged 3.5 cm in length (range, 1 to 10 cm); the severity of the lesions was indicated by the fact that, in all instances, patients were completely intolerant of solids, and was confirmed fluoroscopically by demonstration of significant luminal narrowing. A mean of 4.3 steroid injections (range, 1 to 8) was required to obtain complete remission of symptoms; there have been no complications except in one lye ingestion patient who developed a tiny perforation following the initial dilatation, which responded to antibiotics alone. All patients remain symptom-free; the mean length of follow-up is 6.2 years (range, 1 to 11 years). We conclude that string-guided esophageal dilatation, when coupled with endoscopically guided steroid injection, is a safe and reliable method for treatment of severe esophageal strictures, which should obviate the need for esophageal resection or replacement in most patients. Moreover, even if treatment should ultimately fail, a procedure of lesser magnitude than esophageal replacement will likely be possible.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R P Gandhi
- Division of Pediatric Surgery, College of Physicians and Surgeons, Columbia University, New York
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