Advances in the treatment of postoperative anastomotic strictures in esophageal cancer a comparative analysis of the efficacy of endoscopic versus interventional dilatation.

The management of locally advanced esophageal cancer typically involves esophagectomy; however, postoperative complications, particularly anastomotic stricture, remain prevalent. Anastomotic stricture can severely compromise patients' quality of life by leading to difficulties in food intake. Although endoscopic balloon dilation has become a standard treatment for gastrointestinal strictures, its efficacy is often limited due to the risk of perforation and the potential for recurrent stricture, necessitating multiple interventions. Recent advancements have introduced endoscopic radial incision and cutting methods, which aim to enhance patency by excising scar tissue. We experienced a case resistant to the radial incision and cutting therapy, necessitating further intervention strategies. This report details our experience utilizing a novel technique, endoscopic incisional balloon dilation, which combines endoscopic incisional technique and balloon dilation therapy with anti-scarring medications, in cases of refractory anastomotic strictures following esophageal cancer resection. We present three challenging cases in which endoscopic incisional balloon dilation yielded significant clinical improvements, alongside supportive literature. Our findings suggest that endoscopic incisional balloon dilation is an effective and safer alternative to conventional methods, capable of addressing complex stricture scenarios while potentially enhancing patient outcomes and quality of life.

Adverse events associated with EGD and EGD-related techniques

Purpose. Postoperative benign colorectal anastomotic strictures are not rare, and a wide range of procedures has been used in their treatment, such as endoscopic dilation techniques. This study evaluates the outcome of using a specific multidiameter balloon for endoscopic dilation. Methods. The records of 8 patients with postoperative anastomotic strictures (of less than 5 mm in diameter), with or without diverting stoma, from January 2003 to December 2006 were reviewed retrospectively. Seven patients underwent the standard endoscope-guided dilation procedure using a CRE(superscript TM) wire-guided balloon dilator, resulting in closure of the diverting stoma following a successful dilation procedure. Results. The mean duration of postoperative follow-up was 18.3 months (range, 2-41 months). Six patients had one session of balloon dilation while two had 2 sessions, with an average of 1.25 sessions/person. There was no recurrence within 18.3 months (range, 2-41 months) of follow-up (post dilation and closure of stoma). None of the patients experienced any post balloon dilation complications. Conclusions. Endoscope-guided balloon dilation using a multidiameter balloon is a simple and safe method for managing anastomotic strictures. The diverting stoma should be closed as soon as possible following successful dilation, as stool passage acts as a natural dilator and may reduce the rate of recurrence.

Endoscopic Wedge Excisions with CO2 Laser for Subglottic Stenosis.

<br><b>Introduction:</b> The prevalence of Crohn's disease amounts to 5.9 cases per 100,000 population. Complications such as intestinal strictures usually occur within a long course of Crohn's disease. Intestinal resection for stricture does not prevent a stricture recurrence and the need for repeated resections, which in turn leads to the formation of short intestine syndrome. The advantage of endoscopic balloon dilatation is organ preservation and a quick clinical therapeutic effiect. However, the frequency of recurrences after conventional endoscopic balloon dilatation of the intestinal stricture in Crohn's disease is still at a relatively high level and amounts to 59%, which justifies the need to improve the endoscopic dilatation technique.</br> <br><b>Aim:</b> The aim of this study to improve the treatment effectiveness for intestinal strictures in Crohn's disease using endoscopic balloon dilatation combined with prednisolone injection in the stricture area.</br> <br><b>Materials and methods:</b> Endoscopic treatment for intestinal strictures in Crohn's disease was performed in 64 patients. Depending on the endoscopic technique, patients were randomized into 2 groups. The first group consisted of 32 (50%) patients who underwent conventional endoscopic balloon dilatation of strictured areas. The second group consisted of 32 (50%) patients in whom an endoscopic balloon dilatation in combination with submucosal injection of prednisolone to the area of stricture after dilatation was performed. Patient groups were comparable in age, sex and length of stricture.</br> <br><b>Results and conclusions:</b> The results showed that endoscopic balloon dilatation with administration of 40 mg of prednisolone in group II patients was more effective compared to conventional balloon dilatation. The recurrence rate was reduced from 34.4% to 9.3%. The risk of recurrence of intestinal stricture in group I during the first year of observation was found to be 4.5 times higher - HR = 4.5 (1.6-12.9); P = 0.010. The effectiveness of advanced endoscopic balloon dilatation for intestinal strictures was confirmed by colonoscopy with patomorphological examination of the intestinal mucosa 6 months after dilation in patients of both groups.</br&gt.

Objective To explore the effects of bouginage versus combination of esophageal bouginage and balloon dilatation for anastomotic stricture after surgery for esophageal cancer. Methods 40 esophageal cancer patients with postoperative anastomotic stricture without recurrence confirmed by gastrocopy were divided into group A and group B, 20 for each group. Group A were treated with esophageal bouginage, and group B with esophageal bouginage and balloon dilatation. The esophageal lumen diameter and Stooler’s dysphagia score before and after the dilation were compared between the two groups. The treatment results of the two group were analyzed. Results 7 cases were significantly effective, 12 relatively effective, and 1 ineffective in group A, with a total effective rate of 95.0%; 8 cases were significantly effective and 12 cases were relatively effective in group B, with a total effective rate of 100.0%. Conclusion Bouginage versus combination of esophageal bouginage and balloon dilatation for anastomotic stricture after surgery for esophageal cancer both are effective in improve the stricture, food intaking, and their satisfaction, but the combination is better. Key words: Bouginage; Combination of esophageal bouginage and balloon dilatation; Anastomotic stricture

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass.

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass

Background: The present study aims to evaluate the efficacy of early endoscopic evaluation with balloon dilatation performed during non-symptomatic post-operative period with the intent of preventing benign post-operative esophagojejunal anastomotic strictures in patients who receive total gastrectomy for gastric cancer. Methods: First, we retrospectively compared the prevalence of benign esophagojejunal anastomotic stricture occurred 1 month after total gastrectomy for gastric cancer in early endoscopic evaluated group using balloon dilatation (n = 61) with non-evaluated group (n = 148); and then we reviewed the relationship between benign anastomotic stricture and other clinicopathological parameters, including gender, age, body mass index (BMI), and tumor, node, metastasis (TNM) stage. Results: The total number of patients was 209, with 139 men and 70 women, and with an average age of 57.8 years. The endoscopic evaluation with or without balloon dilatation on the 10th post-operative day (POD) was performed in 61 out of 209 patients. Of them, benign post-operative anastomotic stricture was found in 17 patients (27.9%). In the remaining 148 patients, benign post-operative anastomotic stricture occurred in 14 (9.5%) patients. In the 61 patients who received early endoscopic evaluation, 16 received preventive balloon dilatation at the same time and four of them showed benign stricture (4/16, 25%). Of the remaining 45 patients who was endoscopically evaluated without balloon dilatation, 13 had benign strictures (13/45, 28.9%). Preventive endoscopic balloon dilatation (EBD) on the 10th POD was not statistically related to post-operative stricture in a total of 209 patients (P = 0.260) and in early gastrofiberscopy (GFS) sub-group (P = 1.000). A multivariable logistic regression analysis showed that pre-operative BMI (P = 0.014) and endoscopy on the 10th POD (P = 0.001) were independent predictors of post-operative anastomotic stricture. Conclusions: Endoscopic procedure with balloon dilatation, which we had expected to prevent stenosis by widening the internal diameter of the anastomosis site in early post-operative period after total gastrectomy, does not prevent stenosis but rather promotes post-operative stricture. In addition, the lower the pre-operative BMI is, the more frequent post-operative benign anastomotic stricture will be. J Curr Surg. 2019;000(000):000-000 doi: https://doi.org/10.14740/jcs370

Background: Benign esophageal strictures are treated endoscopically, often with balloon dilatation (BD) or bougie dilators. However, recurrent esophageal strictures have been reported after BD, and severe complications sometimes occur. The aim of this study was to compare the efficacy and complications of endoscopic incisional therapy (EIT) and BD for benign esophageal strictures.Methods: We retrospectively reviewed patients who underwent BD or EIT as primary treatment for benign esophageal strictures between July 2014 and June 2021. Technical success was defined as restoration of the lumen diameter with <30% residual stenosis. Clinical success was defined as no recurrence of dysphagia within 1 month after BD or EIT and an increase of 1 grade or more on the Functional Oral Intake Scale.Results: Thirty patients with benign esophageal stricture were enrolled. There were 16 patients in the BD group and 14 patients in the EIT group. No significant differences in technical and clinical success rates were found between the two groups. Furthermore, no significant differences in the re-stricture rate were observed between the groups. There was one complication in the EIT group and three complications in the BD group. Three patients who underwent BD had re-stricture and underwent EIT thereafter, and we regrouped patients who underwent EIT at least once. The clinical success rate was significantly higher in patients regrouped to the EIT group than in patients who underwent BD only.Conclusions: EIT is not inferior to BD as the primary treatment for benign esophageal strictures, especially for recurrent cases.

Endoscopic dilatation is the standard therapy for postoperative colorectal anastomotic strictures, although it carries the risk of perforation at the weakest part of the anastomosis. In order to minimize this risk we have developed a combined technique of endoscopic electroincision and hydraulic balloon dilatation. Thirty-six symptomatic patients with benign colorectal anastomotic strictures were referred for endoscopic electroincision with consecutive balloon dilatation, if the diameter of the anastomosis was less than 12 mm (n = 15) or if the diameter was less than 20 mm and the patient complained of repeated obstructive symptoms under conservative therapy (n = 21). Under direct endoscopic control the scar tissue at the anastomotic line was incised radially with the tip of the polypectomy snare or with a papillotome. Endoscopic hydraulic balloon dilatation was then performed, using a pressure of 35 PSI for three minutes. An endoscopic or radiological control was carried out on the second day, and balloon dilatation was repeated if necessary. The combined technique of electroincision and consecutive balloon dilatation was performed successfully in 35 patients. In only one patient this therapy could not be performed, because of a long stenotic segment, and surgery was necessary. In 24 patients one single dilatation was sufficient after electroincision, whereas six patients required two, and five patients required three consecutive balloon dilatations. There were no severe complications such as bleeding or perforation. Complete follow-up evaluation was possible in 25 patients. In five cases recurrences appeared within the first year; all could be treated successfully by further balloon dilatation. The combination of endoscopic electroincision and hydraulic balloon dilatation leads to a high long-term clinical success with a minimum of complications. Therefore, in our opinion it is a useful method in the treatment of benign colorectal anastomotic strictures.

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients’ clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass

INTRODUCTION: Metastatic neuroendocrine neoplasms (NENs) are prevalent at initial prognosis. Surgery with the aim to cure is the current recommended guideline. However, there is not data in supporting therapy for complications from surgery. We successfully treated anastomotic stricture using endoscopic dilation, a modality recommended for treating of Crohn’s Disease stricture. CASE DESCRIPTION/METHODS: 69-year-old female with a history of HTN, hypothyroidism and metastatic Small Bowel Carcinoid Tumor s/p small bowel resection complicated by post-op ileus and now high grade small bowel obstruction (SBO). Initially diagnosed with carcinoid with imaging showing 2.2 × 1.4 cm nodularity in small bowel and mesenteric nodal involvement with elevated chromogranin and 5-HIAA. PET scan showed ileocolic mesenteric adenopathy with no hypermetabolic activity noted. Pathology from small bowel resection revealed high grade carcinoid tumor, for which octreotide therapy was initiated. Patient later developed a high grade SBO at the anastomotic site. She underwent colonoscopy and anastomotic stricture with severe stenosis of 3 mm was noted 10 cm from the ileocecal valve. A Visiglide wire was successfully passed through the stricture under fluoroscopic guidance. She was then serially dilated to 12 mm using a pyloric balloon dilator. Improvement in luminal narrowing was noted after dilation. Output from nasogastric tube began to decrease and her abdominal pain slowly improved. A few days later she began moving her bowels and nasogastric tube was removed. She was advanced from liquid to soft diet and was discharged in stable condition. DISCUSSION: Metastatic intestinal and pancreatic NENs represent 40–50% at initial diagnosis. Besides systemic therapies, current consensus guideline for metastatic NENs recommends for surgical resection with locoregional or ablative therapies. One complication of surgical resection is the development of anastomotic strictures. Strictures in the small bowel are commonly seen in Crohn's Disease. Literature has shown great success with endoscopic balloon dilation for the management of Crohn’s associated strictures. However, small bowel strictures as a complication of surgical resection of carcinoid tumors is not well documented. Our case illustrates how using an endoscopic technique known to manage Crohn’s complications can be novel to cases with similar pathophysiology but different etiology.

Can endoscopic balloon dilation for primary obstructive megaureter be effective in a long-term follow-up?