Bolus Obstruction Research Articles

PTU-014 Safety and efficacy of endoscopic resection followed by radiofrequency ablation for Barrett's high-grade dysplasia and intramucosal cancer

<h3>Introduction</h3> Endoscopic resection (ER) is a minimally invasive treatment for Barrett9s high-grade dysplasia (HGD) and intramucosal cancer (IMC). However, a significant proportion of patients may develop malignant transformation of remaining Barrett9s. Radiofrequency ablation (RFA) is a new, safe and effective modality for eradicating dysplasia and intestinal metaplasia. However there are limited data on the safety and efficacy of a combined approach including ER followed by RFA. <h3>Methods</h3> The aim was to assess the feasibility, safety and efficacy of the combined approach. Patients were enrolled from two tertiary referral centres in UK, as part of a multicentre European trial (EURO II). All visible mucosal lesions were removed by ER. RFA was carried out at 6–8 weekly intervals for a maximum of five sessions. HALO 360 were used for circumferential ablation followed by HALO 90 for any remaining islands. <h3>Results</h3> 20 patients (average age 63, 19 males) with a mean Barrett9s length of 4.8 cm (range 2–11 cm) underwent ER of visible mucosal lesions. All patients had Paris 0-II lesions (IIa-14, IIb-5 and IIc-1) with a mean size of 12 mm (range 4–20 mm). ER was carried out using multiband mucosectomy device in 19 patients and ER cap in one patient. En-bloc resection was achieved in eight cases, the rest requiring a piecemeal approach. 10 (50%) patients were up-staged from HGD to IMC following ER. RFA was carried out at least 6 weeks after ER. After a median follow-up of 11 months (IQR 7.5–16.5) and a mean of 2.2 (range 1–5) RFA sessions, none of the patients had residual or recurrent dysplasia. On average, the combined approach resulted in 90% reduction in the endoscopically-observed extent of Barrett9s mucosa. In eight patients who had completed the treatment regimen, complete histological resolution of intestinal metaplasia was achieved. Three patients (15%) developed minor procedure-related complications including 1 food bolus obstruction which was managed endoscopically, 1 superficial mucosal tear and 1 episode of self-limiting chest pain. <h3>Conclusion</h3> Endoscopic resection followed by radiofrequency ablation is a feasible, safe and effective approach for eradicating dysplasia and intestinal metaplasia in Barrett9s oesophagus. Long-term follow-up is warranted before this treatment modality could be implemented in routine clinical practice.

S1507: Prevalence of Eosinophilic Esophagitis in Unselected Patients Presenting to Endoscopy: A Large Prospective Study

The prevalence of eosinophilic esophagitis (EoE) ranged in published literature between 0.02% in population-based studies and up to 48.2% in patients presenting with food bolus obstruction. Most studies were conducted among patients presenting with dysphagia, food impaction or those with suggestive esophageal signs on endoscopy. There is little data from large scale prospective studies among non selected groups of patients undergoing endoscopy. This data is important to understand the possible expanded manifestations of EoE.

Complications of Metallic Stent Placement in Malignant Esophageal Stricture and Their Management

At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience. Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital. Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3+/-59.3 days (range: 2 to 993 d). The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.

Manometric and symptomatic spectrum of motor dysphagia in a tertiary referral center in northern India

We studied the spectrum of motor dysphagia in a northern Indian tertiary referral center. In this retrospective study, consecutive patients with motor dysphagia referred to the Gastrointestinal Pathophysiology and Motility Laboratory from 2002 to 2007 were evaluated clinically and with eight-channel water-perfusion manometry. Causes of dysphagia were diagnosed using standard criteria. Of 250 patients (age 41.3 [15.0] years, 146 men), 193 (77%) had achalasia cardia (AC) and 57 (23%) had other causes (11, 4.4%: diffuse esophageal spasm [DES]; 9, 3.6%: hypertensive lower esophageal sphincter [Hy LES]); manometry was normal in 37 patients. Twenty-seven patients (14%) had vigorous AC. Duration of dysphagia at presentation was longer in those with AC and Hy LES than in normal manometry (NM) (21 months [1-180] vs. 6 [1-360], p = 0.000; 24 months [7-48] vs. 6 [1-360], p = 0.015). Regurgitation and bolus obstruction were more frequent in those with AC than in NM (89/154, 57.79% vs. 3/27, 11.11%, p = 0.000001). Heartburn was less frequent in patients with AC than in others (AC: 4/146, 2.73% vs. normal: 4/27, 14.8% [p = 0.02] and others: 3/15, 20% [p = 0.018]). Chest pain was reported by 74/135 (54.8%) classic and 12/19 (63.2%) vigorous AC (p = NS). Patients with NM had lower LES pressure than those with classic AC, Hy LES and vigorous AC (p < 0.0001 in each case). Patients with DES had lower LES pressure than in classic AC, Hy LES and vigorous AC (p = 0.043, p < 0.0001, and p = 0.002, respectively). Patients with classic AC had lower LES pressure than in Hy LES and vigorous AC (p = 0.024, p = 0.001, respectively). Classic AC was the commonest cause of motor dysphagia in our center. AC was associated with higher LES pressure, longer duration of dysphagia, frequent regurgitation and bolus obstruction.

Eosinophilic Esophagitis: Clinical Features, Endoscopic Findings and Response to Treatment

Eosinophilic esophagitis (EE) is a motility disorder of the esophagus that typically presents with dysphagia. The objective of the present study was to explore patient characteristics, clinical and endoscopic features, and response to treatment of patients with EE. Patients were selected retrospectively based on a review of biopsy results from previous endoscopies performed between 2004 and 2008. A total of 54 patients (41 men and 13 women) with biopsy-proven EE were included in the study. Further information regarding the patients' clinical and endoscopic features, and response to treatment were obtained through chart reviews and patient telephone interviews. The mean age of the patients at symptom onset was 30 years. All patients complained of dysphagia, 81% had a history of bolus obstruction, 43% had a history of asthma and 70% had a history of environmental allergies. Thirty-three per cent had a family history of asthma, while 52% had a family history of food or seasonal allergies. The most common endoscopic findings were rings and⁄or corrugations, which were found in 63% of patients. Swallowed fluticasone therapy resulted in symptom resolution in 74% of patients; however, 79% of these patients relapsed after discontinuing fluticasone therapy and required repeat treatments. Esophageal dilation was complication free and resulted in improvement in 80% of patients. However, 83% of those reporting improvement relapsed within one year. The clinical and endoscopic findings were similar to those found in the literature, with most patients requiring ongoing, repeated therapies. Further studies are needed to assess the safety and efficacy of treatment modalities ideally suited to patients with EE.

Perforation after rigid pharyngo-oesophagoscopy: when do symptoms and signs develop?

Perforation after pharyngo-oesophagoscopy is a serious complication, and its identification, through close patient monitoring, is essential. Yet little is known about when symptoms and signs develop, and thus how long any close monitoring should last. To examine the timing of individual symptoms and signs of perforation after rigid pharyngo-oesophagoscopy. Three-centre, retrospective study. Of 3459 patients undergoing rigid pharyngo-oesophagoscopy, 10 (0.29 per cent) developed perforations, nine of which were suspected intra-operatively. Symptoms and signs developed at 1.5 hours post-operatively at the earliest, and at 36 hours at the latest. Three patients were asymptomatic. The majority of procedures (n = 8) were undertaken for food bolus obstruction or foreign body ingestion. Pharyngo-oesophagoscopy for food bolus obstruction and foreign body ingestion accounts for a large number of perforations, but symptoms and signs may take longer than 24 hours to develop. A contrast swallow should be considered in high risk patients, and a high index of suspicion maintained in order to detect this complication.

Case 1: Diagnosing difficult deglutition

A 16-year-old girl with a long-standing history of dysphagia was referred to the gastroenterology service by her family paediatrician. The difficulty in swallowing had been present intermittently since early childhood and had recently become more prominent, making her seek medical attention. The patient had noticed difficulty swallowing certain types of solid foods, notably meat and bread. She had a feeling of food getting stuck in the throat and of discomfort in that area. On a few occasions, she had vomited undigested food. There was no problem swallowing liquids. There was no odynophagia, heartburn, regurgitation, drooling, abdominal pain, chronic cough, headaches or weight loss. She never presented with a bolus obstruction. Her symptoms were nonprogressive. A system inquiry was negative. She was a well-adjusted adolescent, performing very well in school and being active in sports and extracurricular activities. Her history was unremarkable with normal growth and development. A family history for dysphagia was negative. A physical examination had revealed a healthy looking girl. Her weight was between the 75th and 90th percentile, and her height was above the 97th percentile. Her physical examination was completely normal. A variety of proton pump inhibitors at adequate doses were tried without any response. A barium study had revealed no abnormality in the swallowing mechanism. The esophagus was unremarkable. The patient was referred to the surgical service of her regional hospital, and an upper gastrointestinal endoscopy was performed. The esophagus was reported to be completely normal. Mild, nonspecific erythema was noted in the gastric antrum. However, biopsies taken from the antrum did not reveal any Helicobacter pylori infection. An assessment by an otolaryngologist had revealed a normal larynx and hypopharynx with good vocal cord mobility and no mass effect. Given all the negative investigations, the impression was that the patient may have psychogenic dysphagia. When seen at the gastroenterology clinic, the patient’s symptoms were unchanged and her physical examination was normal. A diagnostic test was performed. The term dysphagia is derived from the Greek roots “dys” (with difficulty) and “phagia” (to eat). It is defined as the subjective sensation of having difficulty swallowing and can occur from any process that produces difficulty with active transport of food and liquid from mouth to stomach. In the paediatric population, dysphagia is an uncommon but an alarming symptom. The differential diagnosis of dysphagia in children is wide, including congenital, infectious, inflammatory, systemic, traumatic and neoplastic causes. Dysphagia can be broadly classified into two types, based on its origin: pharyngeal or esophageal. The causes of pharyngeal dysphagia are mainly neuromuscular in nature, causing difficulty in swallowing both liquids and solids – patients typically experience more difficulty swallowing liquids. Esophageal dysphagia may be due to problems in the lumen (tumours, stricture, web, ring, foreign body, etc), wall (esophagitis, connective tissue disorders, achalasia, etc) or extramural (mediastinal mass). This type of dysphagia typically leads to difficulty swallowing solid foods. Occasionally, no etiology is found for dysphagia. Most causes of dysphagia are apparent on the history and physical examination of the patient. A barium swallow is the investigation of choice in dysphagia and would help to exclude anatomical problems.

Thoracic osteophyte: rare cause of esophageal perforation

Esophageal perforation is a difficult problem in thoracic surgery. Esophageal perforations can be spontaneous, iatrogenic, or malignant. We report two cases of esophageal perforations caused by thoracic osteophytes and different management strategies leading to successful outcomes. An 80-year-old male presented with chest pain and dysphagia following a fall. On endoscopy, an esophageal perforation and foreign body was noted which was confirmed as a thoracic osteophyte on computed tomography scan. He was managed conservatively as he declined surgery. A 63-year-old male was admitted with dysphagia following a food bolus obstruction. Following esophagoscopy and dilatation, there was clinical and radiological evidence of perforation. During surgery, a thoracic osteophyte was identified as the cause of perforation. The perforation was closed in layers and the osteophyte was trimmed. Both patients recovered well. Thoracic osteophytes are a rare cause of esophageal perforations and a high index of suspicion is required in patients with osteoarthritis who present with esophageal perforations.

Herpes Simplex and Eosinophilic Oesophagitis: The Chicken or the Egg?

Herpes Simplex and Eosinophilic Oesophagitis: The Chicken or the Egg?

Reply to the letter by A.C. Leong and D.B. Mitchell on “Endoscopic management of oesophageal food bolus obstruction: flexibility is the way forward”

Sir, In reply to the letter by A.C. Leong and D.B. Mitchell [1], the Wrst point raised concerns the two case series published recently on endoscopic disimpaction of food boluses using Xexible endoscopes. These two papers were published long after the review was completed but despite this, they do not add anything to what is already known on the subject, i.e. that Xexible endoscopes can be used to successfully disimpact food boluses wherever they occur in the oesophagus. With regard to the other points, we would agree that Xexible endoscopy is probably safer for removing none sharp food boluses and made this point in the review. It would seem as if Xexible endoscopy is becoming more acceptable as a Wrst line in treatment of these cases, but this is certainly not the norm, as indicated by our Wndings in the e-mail survey. We feel that with the increased use of and availability of TNFLO scopes in ENT departments, the days of the rigid scope are certainly numbered and there will be very few indications for its use in the future [2]. The gastroenterologists just might Wnd themselves with less work to do as the oesophagus becomes the territory of the ENT surgeon.

Achalasie oder Pseudoachalasie? Fallstricke der Diagnostik und Therapieentscheidung

Patient 1 (female, aged 55 years) had for some time complained of morning nausea. She reported symptoms of reflux with regurgitation of food for two-and-a-half years and also dysphagia with retrosternal bolus obstruction for the last eighteen months. Patient 2 (male, aged 84 years) complained of restrosternal dysphagia with each intake of food for one year, weight loss of 12 kg and occasional regurgitation of food. The general condition of patient 1 was only slightly impaired but that of patient 2 markedly reduced. Routine laboratory tests were unremarkable in both. Barium meal in patient 1 revealed fixed narrowing in the region of the esophageal hiatus. The inferior esophageal sphincter was closed but opened under pressure during esophagogastroscopy. At computed tomography (CT) of the thorax and abdomen an esophageal fistula was detected and bronchoscopy confirmed its opening into the esophagus. Barium meal in patient 2 (done at another hospital) demonstrated a spastic esophagus. Manometry of the esophagus revealed at rest an abnormal increase in the inferior esophageal sphincter without relaxation. Patient 1 had an achalasia and an esophagogastric fistula with recurrent aspiration pneumonia, bronchial carcinoma being excluded. The fistula was closed by suture, followed by cardiomyotomy and anterior partial gastric fundectomy. In patient 2 an isolated achalasia had at first been suspected and botulinum toxin injected into the inferior esophageal sphincter. This caused a progressively worse dysphagia. CT of the thorax and abdomen established the diagnosis of a pseudoachalasia due to an adenoma of the cardia, proven by biopsy at an exploratory laparotomy. A stent was implanted in the esophagus: the postoperative course was without complication. Patient 2 with the pseudoachalasia had a relatively short history of dysphagia, marked weight loss and was elderly. This compares with the history in patient 1: shorter period of dysphagia, no weight loss and a younger age. The differential diagnosis between the two conditions may be difficult with routine methods and other imaging modalities: exploratory surgery may be necessary for a definitive diagnosis.

Endoscopic management of oesophageal food bolus obstruction: flexibility is the way forward

Endoscopic management of oesophageal food bolus obstruction: flexibility is the way forward

Esophageal stents for malignant strictures close to the upper esophageal sphincter

Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia. Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES. Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006. Single university center. Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula. Stent placement. Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by chi(2) test, Kaplan-Meier curves, and log-rank testing. Mean distance from the UES to the upper tumor margin was 4.9 +/- 2.6 cm and to the upper stent margin 3.1 +/- 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated. Retrospective design. Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.

An apricot story: view through a keyhole

BackgroundVery few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy.Case presentationA 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy.DiscussionSmall bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods.ConclusionGenerally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.

Delayed Complications after Placement of Self-Expanding Stents in Malignant Esophageal Obstruction: Treatment Strategies and Survival Rate

Placement of self-expanding metal stents is regarded as a safe and effective treatment in patients with incurable malignant esophagogastric obstruction. However, proceeding and possible benefit of re-interventions in patients with recurrent dysphagia due to delayed complications (>4 weeks after stent insertion) is unclear. In 133 patients with malignant stricture of the esophagus or the esophagogastric junction 164 expandable metal stents were placed. About 89 patients were followed up until death. All tumor- or stent-related complications and consequent re-interventions were recorded. The overall incidence of delayed complications was 53.4% (71 of 133 pts.), with 34 patients (25.6%) experiencing more than one complication. Recurrent dysphagia due to tumor ingrowth (22%) or overgrowth (15%), bolus obstruction (21%), stent migration (9%), and development of esophagorespiratory fistula (9%) was successfully treated by dilatation (24%), placement of a second/third stent (27%), laser therapy (16%), and/or placement of a feeding tube (PEG, 19%). The median survival of patients with endoscopic therapy was significantly longer (222 +/- 26 days) compared to patients without re-intervention (86 +/- 14 days, P < 0.0001). Delayed complications after metal stent placement for malignant esophageal stricture are common, but can be treated successfully by endoscopic re-intervention in most cases. Regular interventional therapy may also improve survival.

Buscopan in food bolus obstruction of oesophagus: a randomised controlled single blinded study

Buscopan in food bolus obstruction of oesophagus: a randomised controlled single blinded study

Prevalence of Eosinophilic Esophagitis in Adults With Food Bolus Obstruction of the Esophagus

Acute food bolus impaction is a common emergency in gastrointestinal practice. Management previously used the endoscope with an overtube to allow retrieval of the bolus per os. The push technique using air insufflation and gentle pressure on the bolus provides an alternative approach. Esophageal mucosal biopsy at the time of the initial endoscopy has not been a part of traditional practice. In view of the increasing recognition of eosinophilic esophagitis (EE) as a cause of dysphagia and food bolus obstruction in adults the etiology needs to be reassessed. Forty-three consecutive adults presenting with acute dysphagia secondary to food bolus obstruction of the esophagus were studied. The bolus was advanced into the stomach with the push technique or removed per os with a retrieval net. Protocol biopsies from the proximal and distal esophagus were obtained in 29 patients. Biopsies were contraindicated or not obtained in the remainder. Forty-one patients were successfully treated at endoscopy. Two subjects with a food bolus impacted at the crico-pharyngeal region required general anesthesia with endotracheal intubation for safe removal. Of 29 patients biopsied, 15 had peptic esophageal stricture as the cause. Fourteen patients (all males, mean age 32 y, range 19 to 62 y) had EE identified histologically. This represents 50% of those biopsied. Patients with EE had typical endoscopic features of linear furrows, mucosal rings, or narrow bore esophagus. Most had prior episodes of food bolus obstruction. Food bolus obstruction can be safely managed by the push technique. EE is an important cause of food bolus obstruction that can be suspected on history and endoscopic appearance and confirmed on histology.

The Niti-S Oesophageal Stent Reduces Migration Rates in the Palliation of Malignant Dysphagia

Background: Self-expanding metal mesh stents (SEMS) are frequently used in the palliation of malignant dysphagia. Our Unit has significant experience of both the Ultraflex stent (Boston Scientific, Natick, Mass) and the Niti-S stent (Taewong Medical, Seoul, Korea). A comparative study was conducted to determine the frequency of stent-related complications with the use of Ultraflex and Niti-S stents in one institution. Methods: Between April 2003 and June 2006 135 patients required SEMS insertion for the palliation of malignant oesophageal obstruction. Individuals received either an Ultraflex (n = 72) or a Niti-S (n = 63) stent. The incidence of complications including retrosternal pain, bleeding, perforation, tumour in-growth or over-growth, migration and 30-day mortality was compared. Results: The age, gender distribution, tumour length, stent length and number of days in hospital after stent insertion were similar between the two groups (median (interquartile range)). The number of patients with retrosternal pain, haematemesis, perforation, bolus obstruction, tumour in-growth or over-growth, and 30-day mortality were also similar. However, the incidence of stent migration was significantly less in the Niti-S stent group. Distal oesophageal and oesophago-gastric junction (OGJ) tumours accounted for 82% of patients receiving an Ultraflex stent and 81% of patients receiving a Niti-S stent. Ultraflex stent migration only occurred in distal oesophageal or junctional cases. Conclusion: The Niti-S stent has design features aimed at reducing stent migration and tumour in-growth. This study has demonstrated a significantly reduced migration rate when compared with the Ultraflex stent with no increase in morbidity or mortality. This finding was sustained even in the distal third and OGJ cancers where the risk of migration is greatest. There was a trend towards reduced tumour in-/over-growth. This study supports the development of a prospective randomised trial. Tabled 1 Ultrafex (n = 72) Niti-S (n = 63) p value Age (years) 74 (62-84) 76 (64-83) n/s Male:female 45:27 44:19 n/s Tumour length (cm) 6 (5-8) 6 (5-9) n/s Distal oesophageal tumour 35 26 n/s OGJ tumour 24 25 n/s Stent length (cm) 9 (7-12) 8 (8-12) n/s Post-stent stay (days) 3 (2-4) 3 (2-5) n/s Tumour in-/over-growth 14 9 n/s Stent migration (all tumours) 8 0 0.02 Stent migration (distal oesophageal tumour) 3 0 n/a Stent migration (OGJ tumour) 5 0 n/a 30-day mortality 2 0 n/a n/s - not significant. n/a - not applicable (numbers too small) Open table in a new tab n/s - not significant. n/a - not applicable (numbers too small)

Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer

Stents are commonly used for the palliation of dysphagia from esophageal or gastric cardia cancer. A major drawback of stents is the occurrence of recurrent dysphagia. Large-diameter stents were introduced for the prevention of migration but may be associated with more complications. To compare small- and large-diameter stents for improvement of dysphagia, complications, and recurrent dysphagia. Evaluation of 338 prospectively followed patients with dysphagia from obstructing esophageal or gastric cardia cancer who were treated with an Ultraflex stent (n = 153), a Gianturco Z-stent (n = 89), or a Flamingo Wallstent (n = 96) of either a small diameter (n = 265) or a large diameter (n = 73) during the period 1996 to 2004. Single academic center. Patients with an inoperable malignant obstruction of the esophagus or the gastric cardia, or recurrent dysphagia after prior radiation, with curative or palliative intent for esophageal cancer. Stent placement. Dysphagia score (on a scale from 0 [no dysphagia] to 4 [complete dysphagia]), complications, and recurrent dysphagia. Analysis was by chi2 test, log-rank test, and Cox regression analysis. Improvement in dysphagia was similar between patients with a small- or a large-diameter stent (P = .35). The occurrence of major complications, such as hemorrhage, perforation, fistula, and fever, was increased in patients with a large-diameter Gianturco Z-stent compared with those treated with a small-diameter stent (4 [40%] vs 16 [20%]; adjusted hazard ratio [HR] 5.03, 95% confidence interval [CI] 1.33-19.11) but not in patients with a large-diameter Ultraflex stent or a Flamingo Wallstent. Moreover, minor complications, particularly pain, were associated with prior radiation and/or chemotherapy in patients with a large- or a small-diameter Gianturco Z-stent (HR 4.27, 95% CI 1.44-12.71) but not in those with an Ultraflex stent or a Flamingo Wallstent. Dysphagia from stent migration, tissue overgrowth, and food bolus obstruction reoccurred more frequently in patients with a small-diameter stent than in those with a large-diameter stent (Ultraflex stent: 54 [42%] vs 3 [13%], adjusted HR 0.16, 95% CI 0.04-0.74; Gianturco Z-stent: 21 [27%] vs 1 [10%], adjusted HR 0.97, 95% CI 0.11-8.67; and Flamingo Wallstent: 21 [37%] vs 6 [15%], adjusted HR 0.40, 95% CI 0.03-4.79). Nonrandomized study design. Large-diameter stents reduce the risk of recurrent dysphagia from stent migration, tissue overgrowth, or food obstruction. Increasing the diameter in some stent types may, however, increase the risk of stent-related complications to the esophagus.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.