Benign Strictures Research Articles

334. DEFINITION OF SEVERE BENIGN OESOPHAGEAL STRICTURES AND IDENTIFICATION OF ASSOCIATED RISK FACTORS

Abstract Benign oesophageal strictures (BES) are often easily treated but around 30% progress into recurrent or refractory benign oesophageal strictures (RBES), that need repetitive dilatations. Difficulties of RBES have been widely discussed in the literature, but there is not a well-established consensus regarding the definition of RBES. In this study we wanted to develop a simple definition in relation to aetiology and number of dilatation sessions per stricture. A retrospective study on 242 BES-patients treated with endoscopic dilatation was performed. The primary endpoint was need of further dilatation per procedure, based on total number of dilatation sessions performed and stricture ethology. Univariate and multivariable regression analysis were performed to assess risk factors for RBES. Among 242 patients, 76 had RBES. The need of further dilatation increases with 13% at fifth dilation session and keeps a continuous mean value at 81%. Investigating some aetiologies separately, the point where need increases does vary. The risk of having RBES decreased for distal (Odds Ratio (OR) 0,25 (Confidence interval (CI) 95% 0,09-0,65)) and middle (OR 0,35 (CI 95% 0,13-0,88)) location of the stricture compared to proximal strictures. We propose that a stricture can be defined as RBES when reaching the fifth dilatation session. At that point we also suggest that clinicians should consider additional treatment, in addition to dilatation, in order to resolve the stricture.

Allium stent as a curative treatment for benign ureteral strictures: Preliminary experience, surgical technique, and functional results

ObjectivesTo evaluate the effectiveness and safety of the Allium™ ureteral stent as a curative treatment of benign ureteral strictures.Materials and methodsWe retrospectively reviewed the electronic database of the two centers of patients who underwent ureteral Allium™ positioning for different types of stenosis (benign or malignant). Between April 2017 and May 2021, 151 patients were treated with the Allium™ stent for ureteral strictures including benign and malignant stenosis. In total, 83 of them met the inclusion criteria for benign ureteral stricture and were included in final analysis.ResultsAbout the etiology of strictures, 79 (95.18%) were secondary to ureteroscopy or impacted stones and 4 (4.82%) were secondary to pelvic surgery. The median operating time was 47.9 ± 15.53 min, and the median length of strictures was 2.51 ± 0.84 (1-4) cm. The median time of follow-up was 18 months (range 1–48 months), the overall success rate was 85.5% (71/83), and no intraoperative or perioperative major complications were recorded. Among patients with failure (12 pts, 14.5%): 10 (83.33%) presented ureteral strictures again; among them, 8/10 were patients with a stricture length between 2 and 4 cm, 2 (16.67%) patients with pyelus–ureteral junction stenosis experienced the migration of the stent. All patients who experienced failure were treated surgically either with a robotic or laparoscopic approach.ConclusionsIn our preliminary experience, the Allium™ stent seems to be an effective and safe surgical treatment for benign ureteral stricture. Further analysis and prospective trials are necessary to better define the role of the Allium™ stent in the treatment of benign ureteral strictures.

Laparoscopic antireflux surgery or PPIs in the management of reflux-related esophageal stricture

BackgroundGastroesophageal reflux disease (GERD) is often associated with esophageal stricture, particularly benign esophageal stricture. We aimed to evaluate the effects of balloon catheter dilation (BD) combined with laparoscopic fundoplication (LF) surgery and proton pump inhibitors (PPIs) in patients with reflux-induced esophageal strictures.MethodsWe retrospectively analyzed 116 patients with reflux-induced benign esophageal strictures who underwent balloon dilatation therapy combined with PPIs (BD-PPIs group, n = 58) and balloon dilatation combined with LF (BD-LF group, n = 58). Patients were followed up for 24 months. The outcomes of the patients were monitored, including clinical success, symptom improvement, adverse events, and the frequency of esophagitis.ResultsAt the latest follow-up, the rate of clinical success was higher in BD-LF group than in BD-PPIs group (80.4% vs. 57.7%, P = 0.011). The patients in the BD-PPIs group required more dilation sessions to achieve successful dilation, as compared to those in the BD-LF group (2.1 ± 1.2 vs. 0.7 ± 0.8, P < 0.001). The DeMeester score, number of reflux episodes for which pH was < 4, and lower esophageal sphincter pressure were significantly better in the BD-LF group than in the BD-PPIs group (all P < 0.001). The incidence of reflux esophagitis was higher in the BD-PPIs group than in the BD-LF group, at 24 months (58.8% vs. 18.2%, P = 0.003).ConclusionsBalloon dilatation with concomitant LF is effective and safe for esophageal stricture secondary to GERD. Moreover, antireflux surgery techniques, such as Nissen or Toupet procedure, should be added for reflux-induced benign esophageal stricture.

Endoscopic electroincision of challenging benign biliopancreatic strictures

Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods Three male patients (mean age 33 years, range 9–60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n = 2) and pancreatic duct stenosis due to abdominal trauma (n = 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours. Conclusions Electrosurgical incision of benign biliopancreatic strictures could be considered in selected patients whom conventional dilation techniques fail.

Exhaled volatile organic compounds for cholangiocarcinoma diagnosis

ObjectivesThe difficulties in the early detection consequent to the lack of sensitive biomarkers render patients with cholangiocarcinoma (CCA) to have poor outcomes. Recently, sensitive and specific volatile organic compounds (VOCs) were identified in several cancers. However, the VOC profiles in CCA are not well-studied. Thus, we investigated the VOC profiles in exhaled breath of CCA patients and controls. MethodsWe prospectively collected exhaled breath samples from 30 consecutive patients newly diagnosed with CCA and 30 controls who did not have CCA (seven had benign biliary strictures and 23 had other medical conditions). Exhaled VOCs were identified using gas chromatography mass spectrometry Triple Quadrupoles system. Analysis of the significant differences in VOCs between cases and controls was conducted using supervised multivariate regression analysis. Further validation was performed for these VOCs in another cohort of 18 CCA patients and 22 controls. ResultsLevels of six compounds were significantly different between CCA patients and controls, namely, acetone, isopropyl alcohol, dimethyl sulfide, 1,4-pentadiene, allyl methyl sulfide, and N,N-dimethylacetamide. Acetone and dimethyl sulfide were independently associated with CCA as demonstrated in the multivariate analysis. Using the cut-off value of 8.59 × 107 arbitrary unit (AU), acetone had a sensitivity and specificity of 82.1% and 75.8%, respectively, with an area under the receiving operator curve (AUROC) of 0.85 for the CCA diagnosis. Acetone level was also significantly different between cases and controls in the validation cohort. Using the same cut-off value, the sensitivity, specificity, and AUROC was 59.1%, 66.7%, and 0.85, respectively. ConclusionBreath analysis may potentially be useful for CCA diagnosis. A cohort of patients with early-stage CCA in further studies is needed to confirm the ability of exhaled VOCs for the early detection of CCA.

Risk Factors of Benign Stricture of Anastomotic Stoma after Esophagectomy and Therapeutic Effect of Stent Implantation.

With the increase in the number of patients and prolongation of their lives after esophagectomy for esophageal cancer, the quality of life after surgery has attracted more and more attention. Although anastomotic stenosis is a common complication, it seriously affects the quality of life and psychological state of patients or even threatens their lives. At present, the exact independent influencing factors of anastomotic stenosis after esophageal cancer surgery have not been determined, and relevant treatment options are still controversial. Here, we analyzed the independent risk factors leading to good postoperative anastomotic stenosis, in order to provide a basis for late prevention. At the same time, we deeply discussed the advantages and safety of stent implantation in the treatment of anastomotic stenosis.

Efficacy of bougie dilation for normal diet in benign esophageal stricture

Objectives Bougination is one of the first-line treatments in benign esophageal stricture (BES). The aim of the study was to identify clinical and endoscopic factors affecting the achievement of a normal diet with only bougie dilation in patients with BES. Patients and methods Patients treated with only bougination for BES at three hospitals were retrospectively investigated. Data including patient demographics, stricture and procedural characteristics were collected. Clinical success was defined as normal diet without additional procedures for two months after bougination. Clinical success rate and associated factors were assessed. Results A total of 121 patients with BES were included. The most common cause of BES was post-operative stricture (n = 55). Finally, 43 (36%) patients were able to eat a normal diet with only bougination. Of these patients, 42 (97.7%) achieved clinical success in the first three sessions or less. Among causes of stenosis, corrosive injury had the lowest success rate (9/40, 22.5%). Clinical success rate was significantly higher for those with the length of stricture of less than 2 cm (47.2%), those with pre-procedural dysphagia of semi-solid or soft diet (51.3%) and those with dilation of 13 mm or more (46.1%). However, the duration of symptom, the number of previous endoscopic treatments and the location of stenosis were not related to clinical success. Conclusions Normal diet is possible in one-third of BES after bougination alone. Predictable factors for achieving a normal diet were less than four sessions of dilation, short length of stricture, pre-procedural dysphagia status and diameter of dilator.

Innovative Upper Gastrointestinal Stenting: Reboring the Blocked Path

Self-expanding metal stents (SEMS) have been established beyond doubt as an effective tool in the palliative management of malignant gastrointestinal tract strictures. The advent of fully covered retrievable SEMS has allowed its use in benign oesophageal strictures and gastric outlet obstruction, which are traditionally treated with balloon or bougie dilation. Although balloon and bougie dilations are effective, strictures may be refractory, requiring repeated sessions of dilation or complex surgeries. Endoluminal stenting spares the patient from complex surgical procedures and their associated complications. Here, the authors present four cases wherein fully covered SEMS were used as an effective therapy for the restoration of the gastrointestinal lumen in non-malignant conditions.

Clinical efficacy of endoscopic dilation combined with bleomycin injection for benign anastomotic stricture after rectal surgery.

Benign anastomotic stricture is a frequent complication after rectal surgery. This study investigated the feasibility of endoscopic dilation combined with bleomycin injection for benign anastomotic stricture after rectal surgery. 31 patients who diagnosed with benign anastomotic stricture after rectal surgery were included in this study. 15 patients received simple endoscopic dilation (dilation group) and 16 patients received endoscopic dilation combined with bleomycin injection (bleomycin group). The clinical effect and adverse events were compared in the 2 groups. The strictures were managed successfully and the obstruction symptoms were relieved immediately. There were 2 minor complications in dilation group and 3 minor complications in bleomycin group. The difference was not significant between the 2 groups (P > .05). During the follow-up, the mean reintervention interval was 4.97 ± 1.00 months in dilation group and 7.60 ± 1.36 months in bleomycin group. The median treatment times was 4 (range 3–5) in dilation group and 2 (range 2–3) in bleomycin group. The differences in the 2 groups were significant (P < .05). Compared with endoscopic dilation, endoscopic dilation combined with bleomycin injection may reduce the treatment times and prolong the reintervention interval, which is a safe and effective endoscopic management for benign anastomotic stricture after rectal surgery.

Management Strategies for Benign Biliary Strictures

AbstractBiliary stricture is the abnormal narrowing of the biliary ductal system, leading to bile stasis and eventual ductal obstruction and dilatation. Common etiologies of biliary strictures can be broadly classified based on benign or malignant causes. The pathogenesis of benign biliary strictures (BBSs) can be a sequela of several causes, including iatrogenic, inflammatory, ischemic, infectious, and immunologic etiologies. Among the common causes of BBS, an iatrogenic biliary ductal injury sustained during hepatobiliary surgeries is the most frequently reported cause of BBS. Clinically, patients with BBS can present with obstructive biliary symptoms, and urgent biliary decompressive interventions are frequently required to prevent fatal complications. Cross-sectional imaging such as MR cholangiopancreatography enables timely evaluation of the stricture and facilitates therapeutic planning. The primary objective in managing biliary strictures (both benign and malignant) is to achieve permanent ductal patency and minimize the need for repeated interventions. A multidisciplinary team of gastroenterologists, interventional radiologists, and hepatobiliary surgeons is generally involved in caring for patients with BBS. This review provides a summary of clinically available endoscopic, percutaneous, and surgical biliary interventions for the management of patients with BBS.

Effect of fully covered self-expandable metal stents completely inserted into the common bile duct in the treatment of benign biliary stricture

Objective: To investigate the safety and efficacy of fully covered self-expandable metal stents(FCSEMS) completely inserted into the common bile duct in the treatment of benign biliary stricture(BBS). Methods: From December 2018 to December 2020, 22 cases of BBS treated by FCSEMS completely inserted into the common bile duct were analyzed retrospectively in the cholelithic center of Shanghai East Hospital Affiliated to Tongji University, including 12 males and 10 females, with average ages of (50.9±8.6) years. Results: All 22 cases of FCSEMS insertion were successful. The average indwelling time was (221.9±19.8) d. There were no complications of enterobiliary reflux such as liver abscess, acute cholangitis, and common bile duct obstruction. FSCEMS proximal displacement occurred in 2 cases (9.1%) with the removal time of 62 min and 115 min, respectively. There was no FCSEMS proximal displacement in 20 cases (90.9), with an average removal time of (29.7±6.3) min. All the 22 cases were followed up for 16.0 (8.0, 25.3) months, and there was no recurrence of stenosis. Conclusion: FCSESM completely inserted into the common bile duct is an effective method for the treatment of BBS, which can avoid the occurrence of enterobiliary reflux.

Role of 99m Tc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome.

Background Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer 99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of 99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy. Methods Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to 99m Tc-Mebrofenin HBS, and the findings were analyzed. Results The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients. Conclusion 99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Patterns of Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Complications

In the treatment of common bile duct stones and palliative decompression of malignant strictures, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard. However, there are still concerns about procedure-related complications and patient discomfort. The aim of the study is to evaluate the pattern of post ERCP complications. This prospective observational study was conducted at the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from February to October 2017. A total of one hundred patients who were eligible for ERCP were included in this study but five patients were excluded due to cannulation failure. Clinical examination , biochemical, and radiological investigation were performed before and after ERCP to assess the complication that occurred. The majority of patients in this study were at and below the age of 50 years, with a mean age of 49.74 ± 14.07 years and the age range was between 18 to 80 years. Majority of the subjects were male (54.7%), and male to female ratio was 1.21:1. The highest number of patients were diagnosed as choledocholithiasis (58.9%) followed by proximal cholangiocarcinoma (13.7%), Ca-gallbladder with biliary infiltration (8.4%), Distal cholangiocarcinoma (6.3%), Chronic calcific pancreatitis and Periampullary carcinoma each (3.2%), Suspected SOD &amp; Chronic pancreatitis each (2.1%) and Worm in CBD and benign biliary stricture each (1.1%). In this study, the overall post-ERCP complication was 12.6%, with pancreatitis accounting for 9.4%, bleeding accounting for 2.1%, and cholangitis accounting for 2.1%. From the study, it can be concluded that pancreatitis is the most frequent Post-ERCP complication. Bangladesh Med J. 2021 May; 50(2) : 35-39

Relationship between etiology and morphological classification of benign central airway stenosis and its prognosis

Objectives: To analyze the relationship between etiology and morphological classification of benign central airway stenosis and its prognosis. Methods: We performed a retrospective study of the medical records of 453 patients initially diagnosed with benign airway stenosis at Department of Respiratory Diseases in Beijing Tiantan Hospital affiliated to Capital Medical University from January 2003 to October 2019. Of 453 patients, 260 were male. The age of the study population was 12-86(44.0±24.5) years. Results: Among the 453 patients diagnosed with benign central airway stenosis, 161 case (35.5%, including 113 post-tracheostomy tracheal stenosis and 48 post-intubation tracheal stenosis) were iatrogenic; 88 cases were from benign tumors (19.4%), 77 cases from tracheal or bronchial tuberculosis (17.0%), 71 case from tracheal foreign bodies (15.7%). Disease causes varied among different gender or age groups. The main type of stenosis was structural stenosis, of which 241 cases (53.2%) were intra-luminal and 183 cases (40.4%) were scar contracture type. The site of stenosis showed a certain relationship with the causes of stenosis. The stenosis degree was mainly from grade 2 to grade 4 (76.4%), and the length was mainly within 3 cm (84.8%). Single factor analysis on the relationship between disease cause, morphological classification and prognosis of benign central airway stenosis showed statistically better prognosis in groups that were caused by benign tumor, intraductal stenosis or stenosis that were 3-4 in degree and 1-2 degree in length. Conclusion: The common causes of central airway stenosis included iatrogenic stenosis, benign tumor, tracheal or bronchial tuberculosis and tracheal foreign bodies. Benign airway stenosis with different disease causes and morphological classification had different prognosis after bronchoscopic interventional treatment. Clinicians should know the disease causes, morphological characterization and risk factors for benign airway stenosis for earlier diagnosis, treatment or prevention.

Current status of endoscopic ultrasound-guided antegrade intervention for biliary diseases in patients with surgically altered anatomy.

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound-guided antegrade intervention (EUS-AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS-AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS-AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy.

EP-601 Biodegradable stents for benign oesophageal strictures- a single centre experience

Abstract Biodegradable (BD) stents have been used for the management of various oesophageal strictures (ES). The present study aim to evaluate our experience and efficacy of BD stents in benign ES at the endoscopic unit at the James Cook University Hospital, Middlesbrough, UK. Methods A retrospective review of case notes of 9 patients who have undergone endoscopically placement of BD stent for benign ES between March 2010 and November 2020. All 9 patients underwent successful stent placement. None of the patients had previous surgery for their condition. All patients, prior to stenting had oesophageal dilatations, some multiple times. Results Stent placement was successful in all 9 patients. Some patients had stent migration and subsequent re stenting. All patients had benign ES as the cause of dysphagia. One patient had caustic oesophageal stricture, remaining eight had peptic ulceration and GORD as the cause of dysphagia. The median number of dilatations prior to stent placement was 4 (IQR 7), more than the median number of dilatations post stent placement which was 2.0 (IQR: 3.5). Conclusion BD stents offers prolonged dilatation-free interval and reduces the number dilatations in patients with benign oesophageal strictures.

Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation

Percutaneous balloon dilation with or without placement of an external biliary drain is a nonoperative alternative method for treating benign bilioenteric anastomotic strictures. Although this procedure has a high technical success rate, outcomes are less optimal when attempting to dilate refractory tight strictures. For the stricture, cutting balloon can be an option. We present four patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation. To the patients, a peripheral cutting balloon over-the-wire system was inflated, following subsequent conventional non-compliant balloon dilation. After the balloon dilation treatment, an external drainage catheter was placed through the stricture site and maintained for up to 30 days. Technical and end-treatment success was achieved in all four patients. In conclusion, the use of cutting balloon dilation may appear to be a safe and effective alternative method of treatment in patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation.

Management of distal benign biliary stricture

Endoscopic treatment consists of passing the stricture and placement of at least one large bore plastic stent, followed by further sessions of stenting with multiple plastic stents. Temporary placement of multiple plastic stents is the recommended approach in patients with benign biliary strictures. Self-expandable metal stents have a larger diameter compared to plastic stents and can be covered and uncovered. Placement of uncovered metal stents in patients with benign biliary strictures is strongly discouraged. However, covered self-expandable metal stents can be safely placed in selected patients.

Endoscopic approach for a pinhole-like benign stenosis in a pancreaticojejunal anastomosis using a double-balloon endoscope with a clear long cap attachment.

Endoscopic approach for a pinhole-like benign stenosis in a pancreaticojejunal anastomosis using a double-balloon endoscope with a clear long cap attachment.

Simple modifications of conventional esophagogastrostomy after proximal gastrectomy adequately reduces the postoperative reflux esophagitis: a retrospective analysis of posterolateral fundoplication.

While proximal gastrectomy is being performed increasingly frequently for the treatment of gastric cancer, a standard reconstruction method to obtain optimal postoperative quality of life (QOL) still remains to be established. We modified the original esophagogastrostomy technique by introducing an additional posterolateral fundoplication (PLF) technique to minimize the risk of reflux esophagitis in patients undergoing proximal gastrectomy. The aim of this study was to clarify the clinical benefit of PLF. A retrospective analysis of the database was conducted to evaluate the effects of PLF. The data were compared between 44 patients in whom PLF was performed (PLF group) and 17 patients in whom conventional esophagogastrostomy without PLF was performed (C group). A number of incidence of postoperative reflux esophagitis and symptoms were assessed by findings of endoscopic examination and the PGSAS-45 questionnaire, respectively. The incidence of grade B or worse esophagitis after surgery was significantly lower in the PLF group than in the C group (0% vs. 58.8%, P < 0.01). The score for the esophageal reflux subscale, as the main outcome measure of PGSAS-45, was significantly better in the PLF group (PLF: 1.5 vs C: 2.4, P < 0.01). Cohen's d value was 1.75, which suggested a rather large effect size. Postoperative benign anastomotic stricture was encountered in 10 cases (22.7%) of the PLF group and 4 cases (23.5%) of the C group, all of whom were successfully treated by brief endoscopic mechanical dilatation. PLF is an expedient procedure for reconstruction after proximal gastrectomy.